Question 1

The PACU nurse is using the postanesthetic scoring system to determine if a patient is ready to be discharged home after a same-day surgery. The nurse would determine the patient to be ready when the score reaches _______.

Accepted Answer

The answer of The PACU nurse is using the postanesthetic...

Question 2

A patient who is being prepared for discharge after surgery becomes dizzy and weak when getting up to go the bathroom. The nurse would document that this patient has orthostatic hypotension if the patient's heart rate increases by _______beats per minute when moving from the lying to standing position.

Accepted Answer

The answer of A patient who is being prepared for...

Question 3

A patient in the PACU is nauseated and has vomited. Which nursing actions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

The answer of A patient in the PACU is nauseated...

Question 4

A nurse in the PACU is administering an IV fluid bolus to an unconscious patient whose urine output has been less than 10 mL per hour for the last 2 hours. Which findings would indicate that this patient is having an adverse reaction to this treatment? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

A) The development of crackles in the bilateral lung bases suggests fluid overload, which is a potential adverse reaction to an IV fluid bolus.
B) An increase in respiratory rate and depth may suggest that the patient is having difficulty breathing, which could be a sign of fluid overload or other adverse reaction. 
C) The patient's oxygen concentration rising is not an adverse reaction and is actually a positive outcome of fluid administration.
D) An increase in urine output is the intended outcome of an IV fluid bolus and would not be an adverse reaction.
E) Increased incisional pain is not a typical adverse reaction to an IV fluid bolus.

Question 5

The surgical unit has developed a new fast-track system whereby patients are transferred from the operating room to PACU phase II. The nurse anticipates that which patients would benefit from this change? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

Patients who undergo minor or less invasive surgeries, and are generally healthy, are good candidates for fast-track systems. This includes a healthy 50-year-old with uncomplicated cataract surgery (A), a 20-year-old basketball player with arthroscopic knee repair (B), and a 5-year-old with tonsil and adenoid removal (E). These procedures typically have quicker recovery times, allowing for a faster transition through post-operative care phases. In contrast, a 65-year-old woman undergoing a hysterectomy for uterine cancer (C) and a 40-year-old man having coronary bypass surgery (D) would likely require more intensive post-operative monitoring and care, making them less suitable for fast-track systems.

Question 6

The PACU nurse is assessing a postoperative patient's intravenous fluids. Which assessments should be documented? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

The answer of The PACU nurse is assessing a postoperative...

Question 7

A nurse is providing care to a patient who had surgery 5 days ago. Today the patient's right calf is red, warm, swollen, and painful. Which interventions should the nurse implement? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

The answer of A nurse is providing care to a...

Question 8

A child who weighs 30 kg is in the PACU. The nurse would collaborate with the child's health care provider if the child's urine output was less than ______ mL per hour.

Accepted Answer

The answer of A child who weighs 30 kg is...

Question 9

Which finding would the PACU nurse evaluate as indicating the patient is progressing toward maintaining his own airway?

Accepted Answer

When a patient starts to "fight" or resist the oral airway, it indicates that they are regaining their gag and cough reflexes, which are crucial for maintaining their own airway. This is a sign of improvement in their ability to protect and maintain their airway independently.

Question 10

A patient recovering from surgery reports a pain level of 6 on a 0 to10 pain scale but refuses additional pain medication to avoid becoming addicted. The nurse's response should focus on which concept?

Accepted Answer

The patient's fear of addiction may indicate a lack of understanding about pain management, and the nurse's response should focus on educating the patient about the importance of adequate pain relief. While it is important to assess for potential addiction problems, this is not the primary concern in this scenario. Placebos are not appropriate in this situation, and it may not be necessary to involve the physician for every patient's pain management plan.

Quiz 19: Postoperative Nursing

The PACU nurse is using the postanesthetic scoring system to determine if a patient is ready to be discharged home after a same-day surgery. The nurse would determine the patient to be ready when the score reaches _______.

A patient in the PACU is nauseated and has vomited. Which nursing actions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply.

The PACU nurse is assessing a postoperative patient's intravenous fluids. Which assessments should be documented? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply.

A child who weighs 30 kg is in the PACU. The nurse would collaborate with the child's health care provider if the child's urine output was less than ______ mL per hour.

Which finding would the PACU nurse evaluate as indicating the patient is progressing toward maintaining his own airway?

A patient recovering from surgery reports a pain level of 6 on a 0 to10 pain scale but refuses additional pain medication to avoid becoming addicted. The nurse's response should focus on which concept?