Nokea
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.
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A postoperative client reports discomfort but denies serious pain and does not want medication. What action by the nurse is best to promote comfort?
- A. Assess the client's pain on a 0-to-10 scale
- B. Reposition the client gently
- C. Offer a warm blanket
- D. Encourage deep breathing exercises
Correct Answer: B
Rationale: Repositioning the client can help alleviate discomfort without medication, addressing the client's immediate needs. Assessing pain is important but does not directly promote comfort. Offering a blanket or encouraging breathing exercises may help but are less specific to addressing discomfort.
A nurse entering the postoperative area learns which principles about the postoperative period? (Select all that apply.)
- A. All phases require the client to be in the hospital.
- B. Phase I involves immediate recovery in the PACU.
- C. Phase II ends when the client is stable and awake.
- D. Phase III involves extended recovery at home.
- E. Phase III ends when the client is fully recovered.
Correct Answer: B,D,E
Rationale: Phase I occurs in the PACU for immediate recovery, Phase II ends when the client is stable and awake, and Phase III involves extended recovery, often at home. Not all phases require hospitalization, and Phase III does not necessarily end with full recovery but with ongoing recovery at home.
A postoperative client states that the sequential compression devices itch and are too hot. The client asks the nurse to remove them. What response by the nurse is best?
- A. Let me call the surgeon to see if you really need them.
- B. No, you have to use those for 24 hours after surgery.
- C. OK, we can remove them since you are stable now.
- D. To prevent blood clots, you need them a few more hours.
Correct Answer: D
Rationale: According to the Surgical Care Improvement Project (SCIP), prophylactic measures to prevent thrombembolic events, such as sequential compression devices, are continued for 24 hours after surgery. The nurse should explain this to the client to promote compliance. Calling the surgeon is unnecessary, and simply refusing or agreeing to remove them does not address the client's concerns or provide education.
A registered nurse (RN) is watching a nursing student change a dressing and perform care around a Penrose drain. What action by the student warrants intervention by the RN?
- A. Cleaning around the drain per agency protocol
- B. Placing a new sterile gauze under the drain
- C. Securing the drain safety pin to the sheets
- D. Using sterile technique to empty the drain
Correct Answer: C
Rationale: The safety pin that prevents the drain from slipping back into the client's body should be pinned to the client's gown, not the bedding. Pinning it to the sheets could cause the drain to pull out when the client moves. The other actions are appropriate.
A client is experiencing pain after leg surgery but cannot yet have more pain medication. What comfort measures can the nurse provide? (Select all that apply.)
- A. Apply stimulation to the contralateral leg.
- B. Assess the client's willingness to try meditation.
- C. Elevate the client's operative leg and apply ice.
- D. Reduce the noise level in the client's environment.
- E. Turn the TV on loudly to distract the client.
Correct Answer: A,B,C,D
Rationale: Nonpharmacologic measures like contralateral stimulation, meditation, leg elevation with ice, and reducing environmental noise can help manage pain. Loud TV is not an effective diversion and may increase discomfort.