Which assessments are made upon the patient's arrival to the post-anesthesia care unit (PACU) following surgery?
Select all that apply.
Airway
Breathing
Dressing
IV site
Vital signs
Airway
Breathing
Vital signs
Which patient assessment findings would the PACU nurse receive from the circulating nurse during report?
Select all that apply.
Vital
signs
Length of surgery
Oxygen saturation
Anesthetic received
Estimated blood loss
Vital signs
Oxygen saturation
Estimated blood loss
Which patient assessments are completed by the PACU nurse on an ongoing basis?
Select all that apply.
IV infusion rate
Patency of drains
Dressing drainage
Extremity movement
Anesthesia emergence
IV infusion
rate
Patency of drains
Dressing drainage
Extremity movement
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?
Select all that apply.
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?
Select all that apply.
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?
Select
all that apply.
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?
Select all that apply.
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?
Select all that apply.
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?
Select all that apply.
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?
Select all that apply.
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?
Select all that apply.
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"?
Select all that apply.
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?
Select all that apply.
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?
Select all that apply.
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?
Select all that apply.
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?
Select all that apply.
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.