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Which client assessment data are priority for the postanesthesia care nurse?
- A. Bowel sounds.
- B. Vital signs.
- C. IV fluid rate.
- D. Surgical site.
Correct Answer: B
Rationale: Vital signs are the priority in PACU to monitor stability per ABCs. Bowel sounds, IV rate, and surgical site are secondary.
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The nurse received a male client from the postanesthesia care unit. Which assessment data would warrant immediate intervention?
- A. The client's vital signs are T 97°F, P 108, R 24, and BP 80/40.
- B. The client is sleepy but opens the eyes to his name.
- C. The client is complaining of pain at a '5' on a 1-to-10 pain scale.
- D. The client has 20 mL of urine in the urinary drainage bag.
Correct Answer: A
Rationale: Tachycardia, tachypnea, and hypotension (80/40) suggest hypovolemic shock, requiring immediate intervention. Sleepiness, moderate pain, and low urine output are less urgent.
Which problem should the nurse identify as priority for client who is one (1) day postoperative?
- A. Potential for hemorrhaging.
- B. Potential for injury.
- C. Potential for fluid volume excess.
- D. Potential for infection.
Correct Answer: A
Rationale: Hemorrhaging is a life-threatening risk in the first 24–48 hours post-surgery, the priority. Injury, fluid excess, and infection are secondary.
The nurse and the unlicensed assistive personnel (UAP) are working on the surgical unit. Which task can the nurse delegate to the UAP?
- A. Take routine vital signs on clients.
- B. Check the Jackson Pratt insertion site.
- C. Hang the client's next IV bag.
- D. Ensure the client obtains pain relief.
Correct Answer: A
Rationale: Taking vital signs is within UAP scope. Checking drains, hanging IVs, and ensuring pain relief require nursing assessment or licensure.
The nurse is completing the preoperative checklist. Which laboratory value should be reported to the health-care provider immediately?
- A. Hemoglobin 13.1 g/dL.
- B. Glucose 60 mg/dL.
- C. White blood cells 6 (x10³/mm³).
- D. Potassium 3.8 mEq/L.
Correct Answer: B
Rationale: Glucose of 60 mg/dL indicates hypoglycemia, risking perioperative complications, requiring immediate HCP notification. Normal hemoglobin, WBC, and potassium are safe.
The client one (1) day postoperative develops an elevated temperature. Which intervention would have priority for the client?
- A. Encourage the client to deep breathe and cough every hour.
- B. Encourage the client to drink 200 mL of water every shift.
- C. Monitor the client's wound for drainage every eight (8) hours.
- D. Assess the urine output for color and clarity every four (4) hours.
Correct Answer: A
Rationale: Fever post-surgery often stems from atelectasis; deep breathing and coughing prevent respiratory complications, the priority. Hydration, wound monitoring, and urine assessment are secondary.