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The nurse is caring for a patient in the PACU and the patient's blood pressure has dropped from an admission blood pressure of 138/84 to 100/58 with a pulse change of 68-94. SpO2 is 98% on 3 L of oxygen. In which order should the nurse take these actions?
- A. Raise the IV infusion rate.
- B. Assess the patient's dressing.
- C. Increase the oxygen flow rate.
- D. Check the patient's temperature.
Correct Answer: C,A,B,D
Rationale: The first nursing action should be to increase the oxygen flow rate. Since the most common cause of hypotension is volume loss, the IV rate should be increased next. Because hemorrhage is a common cause of postoperative volume loss, the nurse should check the dressing. Finally, the patient should be assessed for vasodilation caused by rewarming.
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The nurse is caring for a patient who is recovering from anaesthesia in the postanaesthesia care unit (PACU). On admission to the PACU, the blood pressure (BP) is 124/70. Thirty minutes after admission, the blood pressure is 112/60, with a pulse of 72 and warm, dry skin. Which of the following actions is the most appropriate for the nurse to implement at this time?
- A. Increase the rate of the IV fluid replacement.
- B. Continue to take vital signs every 15 minutes.
- C. Administer oxygen therapy at 100% per mask.
- D. Notify the anaesthesia care provider (ACP) immediately.
Correct Answer: B
Rationale: A slight drop in postoperative BP with a normal pulse and warm, dry skin indicates normal response to the residual effects of anaesthesia and requires only ongoing monitoring. Hypotension with tachycardia and/or cool, clammy skin would suggest hypovolemic or hemorrhagic shock and the need for notification of the ACP, increased fluids, and high-concentration oxygen administration.
The nurse is caring for a patient and during the second postoperative day after abdominal surgery, the nurse obtains an oral temperature of 38.2°C (100.8°F). Which of the following actions should the nurse take first?
- A. Have the patient use the incentive spirometer.
- B. Assess the surgical incision for redness and swelling.
- C. Administer the ordered PRN acetaminophen.
- D. Notify the patient's health care provider about the fever.
Correct Answer: A
Rationale: A temperature of 38.2°C (100.8°F) in the first 48 hours is usually caused by atelectasis, and the nurse should have the patient cough and deep breathe. This problem may be resolved by nursing intervention, and therefore notifying the health care provider is not necessary. Acetaminophen will reduce the temperature, but it will not resolve the underlying respiratory congestion. Because evidence of wound infection does not usually occur before the third postoperative day, assessment of the incision is not likely to be useful.
The nurse is caring for a patient who is recovering from anaesthesia in the postanaesthesia care unit (PACU), and the vital signs are blood pressure 118/72, pulse 72, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which of the following actions should the nurse take at this time?
- A. Place the patient in a side-lying position.
- B. Encourage the patient to take deep breaths.
- C. Prepare to transfer the patient from the PACU.
- D. Increase the rate of the postoperative IV fluids.
Correct Answer: B
Rationale: The patient's borderline SpO2 and sleepiness indicate hypoventilation. The nurse should stimulate the patient and remind the patient to take deep breaths. Placing the patient in a lateral position is needed when the patient first arrives in the PACU and is unconscious. The stable BP and pulse indicate that no changes in fluid intake are required. The patient is not fully awake and has a low SpO2, indicating that transfer from the PACU is not appropriate.
The nurse is caring for a patient who is just waking up after having a general anaesthetic and the patient is agitated and confused. Which of the following actions should the nurse take first?
- A. Check the O2 saturation.
- B. Administer the ordered opioid.
- C. Take the blood pressure and pulse.
- D. Notify the anaesthesia care provider.
Correct Answer: A
Rationale: Emergence delirium may be caused by a variety of factors. However, the nurse should first assess for hypoxemia. The other actions also may be appropriate, but are not the best initial action.
The nurse is caring for a patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU), who is restless and shouting at the nurse. The patient's oxygen saturation is 99%, and recent laboratory results are all normal. Which of the following actions by the nurse is most appropriate?
- A. Insert an oral or nasal airway.
- B. Notify the anesthesia care provider.
- C. Orient the patient to time, place, and person.
- D. Be sure that the patient's IV lines are secure.
Correct Answer: D
Rationale: Because the patient's assessment indicates physiological stability, the most likely cause of the patient's agitation is emergence delirium, which will resolve as the patient wakes up more fully. The nurse should ensure patient safety through interventions such as raising the bed rails and securing IV lines. Emergence delirium is common in patients recovering from anaesthesia, so there is no need to notify the anaesthesiologist. Insertion of an airway is not needed because the oxygen saturation is good. Orientation of the patient is needed but is not likely to be effective until the effects of anaesthesia have resolved more completely.