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A surgical patient has been in the PACU for the past 3 hours. What are the determining factors for the patient to be discharged from the PACU? Select all that apply.
- A. Absence of pain
- B. Stable blood pressure
- C. Ability to tolerate oral fluids
- D. Sufficient oxygen saturation
- E. Adequate respiratory function
Correct Answer: B,D,E
Rationale: A patient remains in the PACU until fully recovered from the anesthetic agent. Indicators of recovery include stable blood pressure, adequate respiratory function, and adequate oxygen saturation level compared with baseline. Patients can be released from PACU before resuming oral intake. Pain is often present at discharge from the PACU and can be addressed in other inpatient settings.
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The nurse is admitting a patient to the medicalsurgical unit from the PACU. What should the nurse do to help the patient clear secretions and help prevent pneumonia?
- A. Encourage the patient to eat a balanced diet that is high in protein
- B. Encourage the patient to limit his activity for the first 72 hours
- C. Encourage the patient to take his medications as ordered
- D. Encourage the patient to use the incentive spirometer every 2 hours
Correct Answer: D
Rationale: To clear secretions and prevent pneumonia, the nurse encourages the patient to turn frequently, take deep breaths, cough, and use the incentive spirometer at least every 2 hours. These pulmonary exercises should begin as soon as the patient arrives on the clinical unit and continue until the patient is discharged. A balanced, high protein diet; visiting family in the waiting room; or taking medications as ordered would not help to clear secretions or prevent pneumonia.
The nursing instructor is discussing postoperative care with a group of nursing students. A student nurse asks, Why does the patient go to the PACU instead of just going straight up to the postsurgical unit? What is the nursing instructors best response?
- A. The PACU allows the patient to recover from anesthesia in a stimulating environment to facilitate awakening and reorientation
- B. The PACU allows the patient to recover from the effects of anesthesia, and the patient stays in the PACU until he or she is oriented, has stable vital signs, and is without complications
- C. Frequently, patients are placed in the medicalsurgical unit to recover, but hospitals are usually short of beds, and the PACU is an excellent place to triage patients
- D. Patients remain in the PACU for a predetermined time because the surgeon will often need to reinforce or alter the patients incision in the hours following surgery
Correct Answer: B
Rationale: The PACU provides care for the patient while he or she recovers from the effects of anesthesia. The patient must be oriented, have stable vital signs, and show no evidence of hemorrhage or other complications. Patients will sometimes recover in the ICU, but this is considered an extension of the PACU. The PACU does allow the patient to recover from anesthesia, but the environment is calm and quiet as patients are initially disoriented and confused as they begin to awaken and reorient. Patients are not usually placed in the medicalsurgical unit for recovery and, although hospitals are occasionally short of beds, the PACU is not used for patient triage. Incisions are very rarely modified in the immediate postoperative period.
The perioperative nurse is preparing to discharge a female patient home from day surgery performed under general anesthetic. What instruction should the nurse give the patient prior to the patient leaving the hospital?
- A. The patient should not drive herself home
- B. The patient should take an OTC sleeping pill for 2 nights
- C. The patient should attempt to eat a large meal at home to aid wound healing
- D. The patient should remain in bed for the first 48 hours postoperative
Correct Answer: A
Rationale: Although recovery time varies, depending on the type and extent of surgery and the patients overall condition, instructions usually advise limited activity for 24 to 48 hours. Complete bedrest is contraindicated in most cases, however. During this time, the patient should not drive a vehicle and should eat only as tolerated. The nurse does not normally make OTC recommendations for hypnotics.
The nurse in the ED is caring for a man who has returned to the ED 4 days after receiving stitches for a knife wound on his hand. The wound is now infected, so the stitches were removed, and the wound is cleaned and packed with gauze. The ED doctor plans to have the man return tomorrow to remove the packing and resuture the wound. You are aware that the wound will now heal by what means?
- A. Late intention
- B. Second intention
- C. Third intention
- D. First intention
Correct Answer: C
Rationale: Third-intention healing or secondary suture is used for deep wounds that either had not been sutured early or that had the suture break down and are resutured later, which is what has happened in this case. Secondary suture brings the two opposing granulation surfaces back together; however, this usually results in a deeper and wider scar. These wounds are also packed postoperatively with moist gauze and covered with a dry, sterile dressing. Late intention is a term that sounds plausible, but is not used in practice. Second intention is when the wound is left open and the wound is filled with granular tissue. First intention wounds are wounds made aseptically with a minimum of tissue destruction.
The nurse is performing the shift assessment of a postsurgical patient. The nurse finds his mental status, level of consciousness, speech, and orientation are intact and at baseline, but the patient tells you he is very anxious. What should the nurse do next?
- A. Assess the patients oxygen levels
- B. Administer antianxiety medications
- C. Page the patients the physician
- D. Initiate a social work referral
Correct Answer: A
Rationale: The nurse assesses the patients mental status and level of consciousness, speech, and orientation and compares them with the preoperative baseline. Although a change in mental status or postoperative restlessness may be related to anxiety, pain, or medications, it may also be a symptom of oxygen deficit or hemorrhage. Antianxiety medications are not given until the cause of the anxiety is known. The physician is notified only if the reason for the anxiety is serious or if an order for medication is needed. A social work consult is inappropriate at this time.