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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.
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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 evaluates that the interventions for the nursing diagnosis of ineffective airway clearance in a postoperative patient have been successful when which of the following goals has been met?
- A. Patient drinks 2-3 L of fluid in 24 hours.
- B. Patient uses the spirometer 10 times every hour.
- C. Patient's breath sounds are clear to auscultation.
- D. Patient's temperature is less than 38°C (100.4°F) orally.
Correct Answer: C
Rationale: One characteristic of ineffective airway clearance is the presence of adventitious breath sounds such as rhonchi or wheezes, so clear breath sounds are an indication of resolution of the problem. Spirometer use and increased fluid intake are interventions for ineffective airway clearance but may not improve breath sounds in all patients. Elevated temperature may occur with atelectasis, but a normal or near-normal temperature does not always indicate resolution of respiratory condition.
The nurse is caring for an unconscious patient who was transferred to the postanaesthesia care unit (PACU) 10 minutes previously and has an oxygen saturation of 88%. Which of the following actions should the nurse take first?
- A. Elevate the patient's head.
- B. Suction the patient's mouth.
- C. Increase the oxygen flow rate.
- D. Perform the jaw-thrust manoeuvre or insert an oral airway.
Correct Answer: D
Rationale: In an unconscious postoperative patient, a likely cause of hypoxemia is airway obstruction by the tongue, and the first action is to clear the airway by manoeuvres such as the jaw thrust or chin lift. Increasing the oxygen flow rate and suctioning are not helpful when the airway is obstructed by the tongue. Elevating the patient's head will not be effective in correcting the obstruction but may help with oxygenation after the patient is awake.
The nurse is caring for a patient who had abdominal surgery two days previously. Which of the following information about the patient is most important to communicate to the health care provider?
- A. The right calf is swollen, warm, and painful.
- B. The patient's temperature is 37.9°C (100.2°F).
- C. The 24-hour oral intake is 600 mL greater than the total output.
- D. The patient complains of abdominal pain at level 6 (0-10 scale).
Correct Answer: A
Rationale: The calf pain, swelling, and warmth suggest that the patient has a deep vein thrombosis, which will require health care provider orders for diagnostic tests and anticoagulants. Because the stress response causes fluid retention for the first 2-5 days postoperatively, the difference between intake and output is expected. A temperature elevation to 37.9°C (100.2°F) on the second postoperative day suggests atelectasis, and the nurse should have the patient deep breathe and cough. Pain with ambulation is normal, and the nurse should administer the ordered analgesic before patient activities.
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.