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A client has arrived in the postoperative unit. What action by the circulating nurse takes priority?
- A. Assessing fluid and blood output
- B. Checking the surgical dressings
- C. Ensuring the client is warm
- D. Participating in hand-off report
Correct Answer: D
Rationale: Hand-offs are a critical time in client care, and poor communication during this time can lead to serious errors. The postoperative nurse and circulating nurse participate in hand-off report as the priority. Assessing fluid losses and dressings can be done together as part of the report. Ensuring the client is warm is a lower priority.
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A postoperative client is being assessed in the postanesthesia care unit (PACU). Which assessment takes priority?
- A. Airway patency
- B. Breathing pattern
- C. Circulation status
- D. Cardiac rhythm
Correct Answer: A
Rationale: Assessing the airway always takes priority, followed by breathing and circulation. Bleeding and cardiac rhythm are part of the circulation assessment, but airway patency is the most critical in the immediate postoperative period.
A nurse is admitting an older client for surgery to the inpatient surgical unit. The client relates a prior history of acute confusion after a previous operation. What interventions does the nurse include on the client's plan of care to minimize the potential for this occurring? (Select all that apply.)
- A. Allow family and friends to visit as the client desires.
- B. Ask the client about coping techniques frequently used.
- C. Keep the client bathed and groomed.
- D. Place the client in a room secluded at the end of the hall.
- E. Provide the client with uninterrupted periods of sleep.
Correct Answer: A,B,C,E
Rationale: To minimize confusion, the nurse should encourage familiar visitors, assess coping techniques, maintain hygiene, and ensure adequate sleep. Secluding the client may increase sensory deprivation and confusion.
A postoperative client has respiratory depression after receiving midazolam (Versed) for sedation. Which medication and dose does the nurse prepare to administer?
- A. Flumazenil (Romazicon) 0.2 to 1 mg
- B. Flumazenil (Romazicon) 2 to 10 mg
- C. Flumazenil (Romazicon) 3 to 15 mg
- D. Naloxone (Narcan) 0.4 to 2 mg
Correct Answer: A
Rationale: Flumazenil is a benzodiazepine antagonist used to reverse the effects of midazolam. The correct dose is 0.2 to 1 mg. Naloxone is an opioid antagonist and would not be appropriate for reversing benzodiazepine-induced respiratory depression.
An older adult has been transferred to the postoperative inpatient unit after surgery. The family is concerned that the client is not waking up quickly and states 'She needs to get back to her old self.' What response by the nurse is best?
- A. Everyone comes out of surgery differently.
- B. Let's just give her some more time, okay?
- C. She may have had a stroke during surgery.
- D. Older people take longer to wake up.
Correct Answer: D
Rationale: Due to age-related changes, older adults may take longer to metabolize anesthetic agents and pain medications, leading to delayed recovery of cognitive status. The nurse should educate the family on this common occurrence. The other responses either lack specific information or suggest rare complications without evidence.
A nurse answers a call light on the postoperative nursing unit. The client states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action should the nurse take first?
- A. Assess the client's blood pressure
- B. Perform hand hygiene and apply gloves
- C. Reinforce the dressing with a clean one
- D. Notify the surgeon immediately
Correct Answer: B
Rationale: Before assessing or treating drainage from the wound, the nurse must perform hand hygiene and don gloves to protect both the client and nurse from infection, adhering to standard precautions.