Nokea
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.
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The nurse is caring for a patient on the first postoperative day who is dizzy when ambulating in the room. In what order will the nurse accomplish the following activities? (All the activities are appropriate.)
- A. Take the patient's blood pressure (BP).
- B. Place the patient in the supine position.
- C. Assist the patient to sit and repeat 5 minutes later.
- D. Record the results.
Correct Answer: B,A,C,D
Rationale: The first priority for the patient with syncope is to prevent a fall, so the patient should be placed in the supine position. Assessment of the BP will determine whether the dizziness is due to orthostatic hypotension, which occurs because of hypovolemia. After taking BP, the patient is assisted to the sitting position and the BP is rechecked in 1-3 minutes. Because this is a common postoperative problem that is usually resolved through nursing measures such as increasing fluid intake and making position changes more slowly, there is no need to notify the health care provider and the nurse is to record the results of the assessment.
The nurse is caring for an older adult in the postanesthesia unit. Which of the following age-related considerations may impact postoperative recovery?
- A. Increased thoracic compliance
- B. Decreased ability to cough
- C. Increased lung tissue
- D. Decreased compliance with deep breathing and coughing
Correct Answer: B
Rationale: The older adult has a decrease in respiratory function, including decreased ability to cough, decreased thoracic compliance (not increased), and decreased (not increased) lung tissue. There is no noted decrease in compliance related to postoperative deep breathing and coughing.
The nurse is caring for a patient with abdominal surgery and on the first postoperative day, the nurse notices new bright-red drainage about 6 cm in diameter on the dressing. Which of the following actions should the nurse implement first?
- A. Reinforce the dressing.
- B. Take the patient's vital signs.
- C. Recheck the dressing in 1 hour for increased drainage.
- D. Notify the patient's surgeon of a potential hemorrhage.
Correct Answer: B
Rationale: New bright-red drainage may indicate hemorrhage, and the nurse should initially assess the patient's vital signs for tachycardia and hypotension. The surgeon should then be notified of the drainage and the vital signs. The dressing may be changed or reinforced, based on the surgeon's orders or institutional policy. The nurse should not wait an hour to recheck the dressing.
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.
After a new nurse has been oriented to the postanaesthesia care unit (PACU), the charge nurse will evaluate that the orientation has been successful when the new nurse does which of the following actions?
- A. Places a patient in the Trendelenburg position when the blood pressure (BP) drops.
- B. Assists a patient to the prone position when the patient is nauseated.
- C. Turns an unconscious patient to the side when the patient arrives in the PACU.
- D. Positions a newly admitted unconscious patient supine with the head elevated.
Correct Answer: C
Rationale: The patient should initially be positioned in the lateral 'recovery' position to keep the airway open and avoid aspiration. The prone position is not usually used and would make it difficult to assess the patient's respiratory effort and cardiovascular status. The Trendelenburg position is avoided because it increases the work of breathing. The patient is placed supine with the head elevated after regaining consciousness.