Nokea
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.
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The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client should the nurse assess first?
- A. Client with a blood pressure of 100/50 mm Hg
- B. Client with a pulse of 118 per minute
- C. Client with a respiratory rate of 8 breaths/min
- D. Client with a temperature of 96°F (35.6°C)
Correct Answer: C
Rationale: The respiratory rate is the most critical vital sign for any client who has undergone general anesthesia or is a postoperative client. A respiratory rate of 8 breaths/min is abnormally low and requires immediate assessment. The other vital signs, while concerning, are less critical in this context.
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.
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 nurse on the postoperative nursing unit provides care to reduce the incidence of surgical wound infection. What actions are best to achieve this goal? (Select all that apply.)
- A. Administer antibiotics for 72 hours.
- B. Dispose of dressings properly.
- C. Ensure a sterile environment in the operating room.
- D. Perform proper hand hygiene.
- E. Remove and replace wet dressings.
Correct Answer: B,D,E
Rationale: Proper disposal of soiled dressings, performing hand hygiene, and removing wet dressings reduce infection risk. Prophylactic antibiotics are typically stopped after 24 hours if no infection is present, and the operating room environment is not the nurse's responsibility on the postoperative unit.
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.