Nokea
The nurse is caring for a patient who has just been transferred to the PACU from the OR. What is the highest nursing priority?
- A. Assessing for hemorrhage
- B. Maintaining a patent airway
- C. Managing the patients pain
- D. Assessing vital signs every 30 minutes
Correct Answer: B
Rationale: The primary objective in the immediate postoperative period is to maintain ventilation and, thus, prevent hypoxemia (reduced oxygen in the blood) and hypercapnia (excess carbon dioxide in the blood). Assessing for hemorrhage and assessing vital sign are also important, but constitute second and third priorities. Pain management is important but only after the patient has been stabilized.
You may also like to solve these questions
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 caring for a patient on the medicalsurgical unit postoperative day 5. During each patient assessment, the nurse evaluates the patient for infection. Which of the following would be most indicative of infection?
- A. Presence of an indwelling urinary catheter
- B. Rectal temperature of 99.5 F (37.5 C)
- C. Red, warm, tender incision
- D. White blood cell (WBC) count of 8,000 /mL
Correct Answer: C
Rationale: Redness, warmth, and tenderness in the incision area should lead the nurse to suspect a postoperative infection. The presence of any invasive device predisposes a patient to infection, but by itself does not indicate infection. An oral temperature of 99.5 F may not signal infection in a postoperative patient because of the inflammatory process. A normal WBC count ranges from 4,000 to 10,000 /mL.
An adult patient is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The patients vital signs and level of consciousness stabilized, but the patient then complains of severe nausea and begins to retch. What should the nurse do next?
- A. Administer a dose of IV analgesic
- B. Apply a cool cloth to the patients forehead
- C. Offer the patient a small amount of ice chips
- D. Turn the patient completely to one side
Correct Answer: D
Rationale: Turning the patient completely to one side allows collected fluid to escape from the side of the mouth if the patient vomits. After turning the patient to the side, the nurse can offer a cool cloth to the patients forehead. Ice chips can increase feelings of nausea. An analgesic is not administered for nausea and vomiting.
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.
The nurse is caring for a patient after abdominal surgery in the PACU. The patients blood pressure has increased and the patient is restless. The patients oxygen saturation is 97%. What cause for this change in status should the nurse first suspect?
- A. The patient is hypothermic
- B. The patient is in shock
- C. The patient is in pain
- D. The patient is hypoxic
Correct Answer: C
Rationale: An increase in blood pressure and restlessness are symptoms of pain. The patients oxygen saturation is 97%, so hypothermia, hypoxia, and shock are not likely causes of the patients restlessness.