Which assessments are made upon the patient's arrival to the post-anesthesia care unit (PACU) following surgery? Show Airway Which patient assessment findings would the PACU nurse receive from the circulating nurse during report? Vital signs Which patient assessments are completed by the PACU nurse on an ongoing basis? IV infusion
rate Which nursing diagnosis would the nurse select for a homeless person admitted to the PACU following emergency surgery? Injury related to patient being homeless Risk for Suicide related to patient being homeless Social Isolation related to patient being homeless Risk for Insufficient Post-Discharge Care related to limited resources
Risk for Insufficient Post-Discharge Care related to limited resources Which nursing diagnosis would the nurse individualize for a patient recovering from left jaw surgery? Risk for Pain related to left jaw surgery Risk for Eating Inability as evidenced by jaw pain Inability to Eat associated with pain from jaw surgery Pain related to jaw surgery as evidenced by complaints Risk for Pain related to left jaw surgery Physical therapy is consulted to assist a postoperative patient who expresses a desire to walk to reduce pain. Which nursing diagnosis will the nurse add to the patient's plan of care? Readiness for Prescribed Treatment Regimen related to physical therapy Readiness for Enhanced Health as evidenced by patient desire to ambulate and promote comfort Impaired Physical Mobility as evidenced by patient need to recover ambulation through physical therapy Readiness for Enhanced Self-Care as evidenced by patient desire to begin mobility exercise to promote comfort Readiness for Enhanced Health as evidenced by patient desire to ambulate and promote comfort Which goal is realistic for a PACU patient complaining of postoperative pain? The patient will be free of pain. The patient will report reduced pain level. The patient will report pain level of 3 or less. The patient will decrease complaints of pain. The patient will report pain level of 3 or less. Which team members would the nurse collaborate with about a patient's impaired physical mobility following surgery? Social worker Home care nurse Physical therapist Discharge planner Respiratory therapist Home care nurse Physical therapist Which team member would the nurse consult when discharging a patient needing wound care? Surgeon Social worker Home care nurse Physical therapist Home care nurse The nurse would collaborate with which team member prior to discharging a patient who has no family support? Surgeon Social worker Home care nurse Health care provider Social worker The nurse would collaborate with which team member about dietary modifications prior to discharging a postoperative patient? Dietician Home care nurse Physical therapist Health care provider Dietician Which initial postoperative nursing intervention takes priority? Elevating the patient's head Assessing the patient's airway Auscultating the patient's lungs Administering oxygen by cannula Assessing the patient's airway Which action should the nurse initially take when a supine postoperative patient complains of breathing difficulty? Reposition the patient Reintubate the patient Suction the patient's airway Encourage the Valsalva maneuver Reposition the patient Which postoperative conditions require immediate intervention by the PACU nurse? Shock Hemorrhage Incisional pain Disorientation Pulmonary embolism Shock Hemorrhage Pulmonary embolism The nurse implemented early ambulation and leg exercises for a patient. Which postoperative complication was the nurse attempting to prevent? Atelectasis Pneumonia Constipation Thrombophlebitis Thrombophlebitis Which interventions should the nurse initiate to prevent a patient from developing postoperative pneumonia? Place patient in Fowler's position Promote fluid intake every 2 hours Monitor pulse oximetry every shift Encourage incentive spirometer use Enforce frequent leg and arm exercises Place patient in Fowler's position Promote fluid intake every 2 hours Encourage incentive spirometer use Which interventions prevent many postoperative complications, including
constipation and deep vein thrombophlebitis? Soft diet Oral laxatives IV fluid therapy Early ambulation Opioid analgesics IV fluid therapy Early ambulation When changing the patient's dressing, the nurse should assess the surgical site for which characteristics? Signs of infection Type of tape closure Placement of drains Condition of dressing Approximation of edges Signs of infection Placement of drains Approximation of edges Which patient assessments are completed by the PACU nurse following the initial admission assessment? Dressings Pain level Vital signs Oxygen saturation Level of consciousness Dressings Pain level Oxygen saturation Which assessment would the PACU nurse perform if a patient were suspected of having an airway obstruction? Gag reflex Mouth inspection Oxygen saturation Level of consciousness Mouth inspection Which assessment finding would alert the nurse to the potential for wound dehiscence? Purulent drainage Granulation tissue Reddened incisional site Edge non-approximation Edge non-approximation Which assessment findings must be present before patients are discharged from the PACU? Free from pain Without nausea Controlled drainage Normal temperature Vital signs at baseline Controlled drainage Normal temperature Vital signs at baseline Which initial assessments would the nurse perform on a patient admitted to the PACU following a lengthy surgery? Respiratory status Neurological status Estimated blood loss Dressings and drains Skin color and temperature Respiratory status Neurological status Which nursing diagnosis would the PACU nurse individualize for a patient with a genetic bleeding disorder? Wound dehiscence related to coagulation issues Risk for impaired skin integrity related to genetic bleeding disorder Impaired skin integrity related to wound dehiscence as evidenced by poor coagulation Risk for postoperative complications related to surgical incision and coagulation disorder ????? Rational makes no sense Which nursing diagnosis would the nurse individualize for a postoperative patient scheduled for discharge who is expressing interest in home self-care? Readiness for enhanced knowledge of disease process Readiness for enhanced comfort as evidenced by patient readiness for discharge Readiness for education as evidenced by patient request for reading materials and videos Readiness for enhanced self-care as evidenced by patient verbalizations of interest in learning Readiness for enhanced self-care as evidenced by patient verbalizations of interest in learning Which nursing diagnosis would the PACU nurse select for a postoperative patient with decreased blood pressure, poor capillary refill, and copious wound drainage? Wound infection Risk for vomiting Risk for hemorrhage Deficient fluid volume Deficient fluid volume Which nursing diagnosis would the nurse select for a patient who develops a fever and purulent incisional drainage 48 hours after surgery? Purulent wound related to incision Risk for infection related to surgery Infection related to surgical incision Impaired skin integrity related to infection Risk for infection related to surgery????? Impaired skin integrity related to infection**** Which nursing diagnosis would the nurse select for a postoperative patient experiencing decreased range of motion and increased fatigue? Activity intolerance Ineffective tissue perfusion Risk for activity intolerance Risk for ineffective tissue perfusion Activity intolerance Which goals are appropriate for a PACU patient
with the nursing diagnosis "Risk for deficient fluid volume related to surgical blood loss and NPO status"? The patient will remain free from hypovolemia The patient will exhibit reduced wound drainage The patient will maintain hemodynamic stability The patient will receive fluid therapy via IV route The patient will exhibit minimal nausea and vomiting The patient will remain free from hypovolemia The patient will maintain hemodynamic stability A patient has the postoperative goal of "The patient will remain free of nausea." The goal is based on which patient need? Need for electrolyte balance Freedom from fluid imbalance Need for hemodynamic stability Avoidance of postoperative discomfort Avoidance of postoperative discomfort Which postoperative patient goal is measurable? The patient will have minimal drainage on leg dressing. The patient will tolerate ice chips for at least two hours. The patient will move all extremities without assistance. The patient will remain comfortable until PACU discharge. The patient will move all extremities without assistance. Which goal would best address a postoperative patient's nursing diagnosis of acute nausea? Being able to eat normally Having normal bowel elimination Having normal fluid and electrolyte levels Having reduced or absent nausea and vomiting Having reduced or absent nausea and vomiting Which team member would the nurse collaborate with about a postoperative patient with shortness of breath? Surgeon Anesthesiologist Speech therapist Respiratory therapist Respiratory therapist Which actions would the PACU nurse implement for a patient going into hypovolemic shock? Establish a patent airway Elevate the head of the bed Administer prescribed IV fluids Administer 2% oxygen by mask Initiate cardiopulmonary resuscitation Establish a patent airway Administer prescribed IV fluids Which nursing actions would the nurse implement for a patient with atelectasis? Suction the airway frequently Encourage frequent coughing Administer expectorant medications Promote use of an incentive spirometer Place patient in Fowler or semi-Fowler position Encourage frequent coughing Promote use of an incentive spirometer Place patient in Fowler or semi-Fowler position Which actions would the nurse implement for a patient with postoperative pneumonia? Hydrate with oral or IV fluids Discourage frequent coughing Maintain in supine flat position Administer prescribed antibiotics Promote use of incentive spirometer Hydrate with oral or IV fluids Administer prescribed antibiotics Promote use of incentive spirometer What is the rationale for administering extra pain medication to postoperative patients who experience chronic pain? Decrease anxiety related to postoperative pain Prevent complications from medication withdrawal Reduce the likelihood of postoperative complications Continue the patient's use of previous pain medications Reduce the likelihood of postoperative complications Which action would the nurse implement for a patient who needs frequent dressing changes but whose skin is irritated by tape? Apply lotion to the irritated skin Leave the dressing off periodically Reduce the number of dressing changes Replace the tape with Montgomery straps Replace the tape with Montgomery straps Which information should the nurse provide to the postoperative patient prior to discharge to home? Wound care Medications Follow-up tests Diet instructions Allowed activities Wound care Medications Diet instructions Allowed activities Which patient response suggests risk for postoperative complications following discharge to home? "I have plenty of room for all the equipment I'll need at home." "I have a plan to meet my incision care needs when I get home." "I'll call my surgeon if I develop the symptoms we discussed earlier." "My daughter can help me with my dressing at least twice each week." "My daughter can help me with my dressing at least twice each week." What is the rationale for having a responsible adult present during postoperative patient teaching? The second adult is a witness that teaching occurred. The patient may be experiencing effects of anesthesia. The witnessing adult assumes teaching responsibility. The adult's presence legally protects the nurse and the surgical facility. The patient may be experiencing effects of anesthesia. Which action should the nurse implement prior to allowing the patient out of bed the first time? Assess the patient's blood pressure. Provide a walker or cane for stability. Request the patient to call for assistance. Advise the patient to move to the chair quickly. Request the patient to call for assistance. Which assessment are made upon the patient's arrival to the postStages of Post-Anesthesia Care
The PACU nurse assesses the level of consciousness, breath sounds, respiratory effort, oxygen saturation, blood pressure, cardiac rhythm, and muscle strength.
What are 3 priority assessments of the PACU nurse?To PACU. Assess air exchange status and note patient's skin color.. Verify patient identity. The nurse must also know the type of operative procedure performed and the name of the surgeon responsible for the operation.. Neurologic status assessment. ... . Cardiovascular status assessment. ... . Operative site examination.. What assessments do you need to make specific to his postoperative care?The following should be checked and recorded: Rate, rhythm and volume of pulse; Blood pressure; Capillary refill time to assess circulatory status, along with the colour and temperature of limbs, also identifying reduced peripheral perfusion.
What is the assessment of a postoperative patient?This assessment should include the intraoperative history and post-operative instructions, circulatory volume status, respiratory status and cognitive state. Common causes of confusion in the postoperative period include infection, hypoxia, sedatives and other medications such as anticholinergics [22].
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Which assessments are made upon the patients arrival to the post anesthesia care unit following surgery?
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