Question 1

The nurse assesses a client who has just been brought to the postanesthesia care unit (PACU).In the operating room,the client's blood pressure was 136/80 mm Hg; it is now 110/80 mm Hg.Urine output was 40 mL/hr and is now 10 mL/hr.Which action by the nurse is best?

Accepted Answer

One of the most sensitive and earliest indicators of vascular volume loss is decreased urine output.The nurse is concerned about urinary output less than 30 mL/hr because this may indicate that the kidneys are not being perfused.The nurse should increase the IV rate.Oral fluids are not an option at this point because the client has not recovered from the anesthesia.Placing the client in Trendelenburg position is not warranted because this puts pressure on the heart and lungs,limiting their effectiveness.Assessing consciousness and pain can wait until later.

Question 2

A client who is being admitted to the postanesthesia care unit (PACU)has weak hand grasps on assessment and is unable to lift his head off the bed.During hand-off report,the nurse notes that the client has received a neuromuscular-blocking agent.What is the nurse's best action?

Accepted Answer

When neuromuscular blocking agents are used,the client is at risk that these agents could be retained.The primary concern is the client's airway owing to muscular weakness.Because the client cannot raise the head and has a weak hand grasp,this may be a potential problem.The nurse should document all assessment findings.Placing the client in Fowler's position and checking the pulses is not warranted.

Question 3

The nurse is assessing a client admitted to the postanesthesia care unit (PACU)after abdominal surgery.The client's respiratory rate is 8 breaths/min and breath sounds are decreased in the bases.What is the nurse's priority action?

Accepted Answer

Additional data are needed to determine respiratory status,so the nurse must finish the assessment with an oxygen saturation (SaO₂)and check the client's level of consciousness.A respiratory rate of less than 10 could indicate an emergency,especially if the SaO₂ drops below 95%.A respiratory rate of less than 10 breaths/min may indicate anesthetic-induced depression.Naloxone should not be administered unless there are clear indications for it,and performing chest physiotherapy may not be warranted.Calling a code or the Rapid Response Team may be needed,but only after a complete assessment.

Question 4

The nurse is caring for a client in the postanesthesia care unit (PACU)2 hours after abdominal surgery.The nurse auscultates the client's abdomen and notes that there are no bowel sounds.What action does the nurse take?

Accepted Answer

Absence of bowel sounds 2 hours after abdominal surgery is an expected finding that should be documented.No intervention specific to this finding is needed at this time.

Question 5

A client who has just been transferred to the postanesthesia care unit (PACU)from surgery is very restless and confused.What is the nurse's first action?

Accepted Answer

The client who is not oriented is at risk of falling.The nurse should remain with the client to ensure safety,and should assign another staff member to the client if care has to be given to others.The client should not be left alone.

Question 6

The nurse reviews the initial postanesthesia care unit (PACU)flow record and notes that the client is alert and oriented -3 when stimulated,pulse is 88 per minute and regular,respirations are 12 per minute and unlabored,and oxygen saturation is 95% on 2 LPM of nasal oxygen.What is the nurse's priority action at this time?

Accepted Answer

Initial assessment on the client entering the PACU that should be recorded on the flow chart record includes level of consciousness,temperature,pulse,respirations,oxygen saturation,and blood pressure.In addition,the nurse should examine the surgical area for bleeding.These items were missing from the initial assessment.

Question 7

The nurse is caring for a client who had surgery 24 hours ago.He is alert and oriented when awakened and reports pain,but goes back to sleep when not being stimulated.He is on patient-controlled analgesia (PCA).What is the nurse's next action?

Accepted Answer

The client should be assessed further before action is taken.If the client cannot stay awake 24 hours after surgery,there may be other problems.The nurse should assess respiratory rate and depth and lung sounds,as well as oxygen status.The nurse should never push the PCA for the client,and pain should be assessed before decisions are made and interventions taken.

Question 8

A client is brought to the postanesthesia care unit (PACU)after surgery that took place with the client in the lithotomy position.Which action does the nurse take after assessing vital signs?

Accepted Answer

The lithotomy position can compromise the client's peripheral circulation in the lower extremities,leading to weak pedal pulses.The nurse should check dorsalis pedis pulses.The client would not need to be assessed for decubiti,turned on the side,nor placed in the Trendelenburg position.

Question 9

The nurse is caring for several clients on the postoperative unit.Which client does the nurse determine has the highest risk of respiratory complications after general anesthesia?

Accepted Answer

Clients who are extremely obese have heavy chest walls that make it difficult to expand the lungs fully.The other clients would not have an elevated risk of respiratory complications.

Question 10

The nurse is caring for a client who has just been brought to the postanesthesia care unit (PACU)after surgery.The client's oxygen saturation is 92% and his hemoglobin is 14 g/dL.What is the nurse's first action?

Accepted Answer

Oxygen saturation is the most definitive assessment finding for whether or not the client is adequately oxygenated.However,because oxygen saturation is based on the amount of hemoglobin in the blood,this indicator needs to be evaluated,in addition to the saturation.If a client has low hemoglobin,even if the percentage of saturation is high,the client is still underoxygenated.Oxygen should be increased and further respiratory assessment performed.

Question 11

The nurse is performing a hand-off report in the PACU.What is the best action for the nurse to perform during the hand-off report?

Accepted Answer

The hand-off report is a time when errors can potentially occur.The nurse should sit with the receiving nurse to give report.That way,both nurses will be focused on the report.Simply handing the information to the new nurse does not ensure that he or she will read or understand it.Following the accepting nurse around and giving report while he or she provides care for other clients would be distracting.The hand-off nurse should not hurry through this report and should provide a report that allows for two-way communication between nurses.

Question 12

A client reports pain 8 hours after surgery.The client has already received an opioid within the past 2 hours.What is the nurse's best action?

Accepted Answer

Opioids are short acting.The client may be undermedicated.The nurse should further assess location,intensity,etc.,of the pain.If the client has no respiratory depression,it is possible that the dose can be increased.The nurse would not call the surgeon until the pain is further assessed.Narcan is used to reverse opioid effects but would not be appropriate in this case.Documentation is important,but the higher priority is a more complete assessment of the client's pain.

Question 13

The nurse is caring for clients in the postanesthesia care unit (PACU).Which client does the nurse intervene for first?

Accepted Answer

The client with an apical radial pulse deficit could be having dysrhythmias,which may be indicative of volume deficit,acidosis,electrolyte imbalances,or hypothermia.All clients must be assessed and cared for according to their needs,but this client would be the nurse's highest priority.

Question 14

The nurse is caring for a client who had abdominal surgery 3 days ago.He tells the nurse,"I felt something 'give way' when I coughed." What is the nurse's best response?

Accepted Answer

Although wound dehiscence is not a common complication after surgery,it is usually painless and the client feels as if something has split or given way.This frequently occurs after coughing.Any client report of such a sensation should be assessed immediately.

Question 15

Postoperatively,a client has a heart rate of 120 beats/min,with dysrhythmias noted on the ECG monitor and a respiratory rate of 34 breaths/min,and is very difficult to arouse.Which action by the nurse is most appropriate?

Accepted Answer

Clients in critical condition are transferred from the operating room directly to the ICU.This client is not stable with elevated heart and respiratory rates,dysrhythmias,and difficulty in arousal.

Question 16

One hour after admission to the postanesthesia care unit (PACU),the postoperative client has become very restless.What is the nurse's first action?

Accepted Answer

The most common causes of restlessness in the immediate postoperative period are hypoxemia and pain.Although pain control is very important,determining the adequacy of ventilation in this case has higher priority.

Question 17

The nurse is changing the client's dressing on the second postoperative day and notes a small amount of serosanguineous drainage.What is the nurse's best action?

Accepted Answer

A small amount of serosanguineous drainage is a normal assessment finding on the second postoperative day.The incision should be cleaned and dressed.

Question 18

A client is being transferred to the postanesthesia care unit (PACU)after surgery.The client has an endotracheal tube (ET)in place.On assessment,the client has oxygen saturation of 95%,respiratory rate of 14 breaths/min,and asymmetric chest wall expansion.What is the nurse's best action?

Accepted Answer

The ET tube could have slipped into the right mainstem bronchus.Auscultating the lungs will help to confirm this; then the nurse should call the health care provider because the tube will need to be pulled back.Attempting to awaken the client will not change the asymmetric chest wall expansion,neither will "bagging" the client or increasing the fraction of inspired oxygen (FIO₂).Because the client's oxygen saturation is still within an acceptable range,this is not warranted.

Question 19

A client had surgical repair of a fractured ankle under local anesthesia and is being transferred from the postanesthesia care unit (PACU)to the surgical floor.Once admitted,what is the nurse's priority action?

Accepted Answer

On admission to the surgical floor from the PACU,the nurse should assess vital signs every 15 minutes F1F1F1S1xF1F1F104,then every 30 minutes F1F1F1S1xF1F1F104 and every 2 hours F1F1F1S1xF1F1F104.After vital signs,the nurse would continue with assessments,including the surgical site and pain.An IV should already be inserted before arrival to the surgical unit.

Question 20

A client has been transferred to the postanesthesia care unit (PACU).Which action does the receiving nurse perform first?

Accepted Answer

After the surgery is completed,the circulating nurse and the anesthesia provider accompany the client to the PACU.A hand-off report that meets National Patient Safety Goal 2 requires effective communication between health care professionals.

Quiz 18: Care of Postoperative Patients

The nurse assesses a client who has just been brought to the postanesthesia care unit (PACU) .In the operating room,the client's blood pressure was 136/80 mm Hg; it is now 110/80 mm Hg.Urine output was 40 mL/hr and is now 10 mL/hr.Which action by the nurse is best?

A client who is being admitted to the postanesthesia care unit (PACU) has weak hand grasps on assessment and is unable to lift his head off the bed.During hand-off report,the nurse notes that the client has received a neuromuscular-blocking agent.What is the nurse's best action?

The nurse is assessing a client admitted to the postanesthesia care unit (PACU) after abdominal surgery.The client's respiratory rate is 8 breaths/min and breath sounds are decreased in the bases.What is the nurse's priority action?

The nurse is caring for a client in the postanesthesia care unit (PACU) 2 hours after abdominal surgery.The nurse auscultates the client's abdomen and notes that there are no bowel sounds.What action does the nurse take?

A client who has just been transferred to the postanesthesia care unit (PACU) from surgery is very restless and confused.What is the nurse's first action?

The nurse is caring for a client who had surgery 24 hours ago.He is alert and oriented when awakened and reports pain,but goes back to sleep when not being stimulated.He is on patient-controlled analgesia (PCA) .What is the nurse's next action?

A client is brought to the postanesthesia care unit (PACU) after surgery that took place with the client in the lithotomy position.Which action does the nurse take after assessing vital signs?

The nurse is caring for several clients on the postoperative unit.Which client does the nurse determine has the highest risk of respiratory complications after general anesthesia?

The nurse is caring for a client who has just been brought to the postanesthesia care unit (PACU) after surgery.The client's oxygen saturation is 92% and his hemoglobin is 14 g/dL.What is the nurse's first action?

The nurse is performing a hand-off report in the PACU.What is the best action for the nurse to perform during the hand-off report?

A client reports pain 8 hours after surgery.The client has already received an opioid within the past 2 hours.What is the nurse's best action?

The nurse is caring for clients in the postanesthesia care unit (PACU) .Which client does the nurse intervene for first?

The nurse is caring for a client who had abdominal surgery 3 days ago.He tells the nurse,"I felt something 'give way' when I coughed." What is the nurse's best response?

Postoperatively,a client has a heart rate of 120 beats/min,with dysrhythmias noted on the ECG monitor and a respiratory rate of 34 breaths/min,and is very difficult to arouse.Which action by the nurse is most appropriate?

One hour after admission to the postanesthesia care unit (PACU) ,the postoperative client has become very restless.What is the nurse's first action?

The nurse is changing the client's dressing on the second postoperative day and notes a small amount of serosanguineous drainage.What is the nurse's best action?

A client is being transferred to the postanesthesia care unit (PACU) after surgery.The client has an endotracheal tube (ET) in place.On assessment,the client has oxygen saturation of 95%,respiratory rate of 14 breaths/min,and asymmetric chest wall expansion.What is the nurse's best action?

A client had surgical repair of a fractured ankle under local anesthesia and is being transferred from the postanesthesia care unit (PACU) to the surgical floor.Once admitted,what is the nurse's priority action?

A client has been transferred to the postanesthesia care unit (PACU) .Which action does the receiving nurse perform first?