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Questions and Answers
A post-operative patient in the PACU begins to exhibit signs of airway obstruction, including stridor and decreased oxygen saturation. What is the priority nursing intervention?
A post-operative patient in the PACU begins to exhibit signs of airway obstruction, including stridor and decreased oxygen saturation. What is the priority nursing intervention?
- Suction the patient's oral cavity
- Place the patient in the Trendelenburg position
- Perform a jaw thrust maneuver (correct)
- Administer IV naloxone
A PACU nurse is assessing a post-op patient who received general anesthesia. The patient's respiratory rate is 8 breaths/min, and their oxygen saturation is 88%. The nurse should first:
A PACU nurse is assessing a post-op patient who received general anesthesia. The patient's respiratory rate is 8 breaths/min, and their oxygen saturation is 88%. The nurse should first:
- Administer naloxone as ordered (correct)
- Apply supplemental oxygen via nasal cannula
- Elevate the head of the bed
- Assess for airway obstruction
A nurse is monitoring a post-anesthesia patient's Aldrete Score. Which score is necessary for discharge from PACU?
A nurse is monitoring a post-anesthesia patient's Aldrete Score. Which score is necessary for discharge from PACU?
- 8
- 6
- 9 (correct)
- 4
A nurse is repositioning a post-op patient in the PACU. Which position is best to prevent airway obstruction?
A nurse is repositioning a post-op patient in the PACU. Which position is best to prevent airway obstruction?
A nurse is caring for a post-op patient who reports severe pain at the surgical site. The nurse notes the patient is hypotensive and tachycardic. What is the priority nursing action?
A nurse is caring for a post-op patient who reports severe pain at the surgical site. The nurse notes the patient is hypotensive and tachycardic. What is the priority nursing action?
A PACU nurse is assessing a patient's neurological status postoperatively. Which findings indicate a delayed emergence from anesthesia? (Select all that apply.)
A PACU nurse is assessing a patient's neurological status postoperatively. Which findings indicate a delayed emergence from anesthesia? (Select all that apply.)
Which nursing interventions help prevent postoperative hypothermia in the PACU? (Select all that apply.)
Which nursing interventions help prevent postoperative hypothermia in the PACU? (Select all that apply.)
A post-op patient reports nausea and vomiting in the PACU. Which interventions are appropriate? (Select all that apply.)
A post-op patient reports nausea and vomiting in the PACU. Which interventions are appropriate? (Select all that apply.)
A nurse is monitoring a post-op patient for circulatory complications. Which findings require immediate intervention? (Select all that apply.)
A nurse is monitoring a post-op patient for circulatory complications. Which findings require immediate intervention? (Select all that apply.)
A PACU nurse is teaching a new graduate about post-op pain management. Which statements indicate correct understanding? (Select all that apply.)
A PACU nurse is teaching a new graduate about post-op pain management. Which statements indicate correct understanding? (Select all that apply.)
A post-op patient in the PACU has a blood pressure of 85/50 mmHg, heart rate of 125 bpm, and cool, clammy skin. What is the priority intervention?
A post-op patient in the PACU has a blood pressure of 85/50 mmHg, heart rate of 125 bpm, and cool, clammy skin. What is the priority intervention?
A patient in the PACU is shivering uncontrollably after a prolonged surgery. Which intervention should the nurse anticipate?
A patient in the PACU is shivering uncontrollably after a prolonged surgery. Which intervention should the nurse anticipate?
A nurse is evaluating a post-op patient's pain. Which assessment findings would indicate inadequate pain control?
A nurse is evaluating a post-op patient's pain. Which assessment findings would indicate inadequate pain control?
A nurse is assessing a post-op patient for airway obstruction. Which sign is the earliest indicator?
A nurse is assessing a post-op patient for airway obstruction. Which sign is the earliest indicator?
A patient in the PACU suddenly develops wheezing, hypotension, and facial swelling after receiving IV antibiotics. What is the nurse's first action?
A patient in the PACU suddenly develops wheezing, hypotension, and facial swelling after receiving IV antibiotics. What is the nurse's first action?
A nurse is monitoring a patient for postoperative nausea and vomiting (PONV). Which patient is at the highest risk?
A nurse is monitoring a patient for postoperative nausea and vomiting (PONV). Which patient is at the highest risk?
Which patient is ready for discharge from PACU based on the Aldrete Score?
Which patient is ready for discharge from PACU based on the Aldrete Score?
A PACU nurse is assessing a patient's surgical dressing. Which finding requires immediate action?
A PACU nurse is assessing a patient's surgical dressing. Which finding requires immediate action?
A patient in the PACU is receiving IV opioids for pain control. The nurse should monitor for which adverse effects?
A patient in the PACU is receiving IV opioids for pain control. The nurse should monitor for which adverse effects?
A nurse is caring for a post-op elderly patient. Which statement about pain management in older adults is correct?
A nurse is caring for a post-op elderly patient. Which statement about pain management in older adults is correct?
A PACU nurse is monitoring a patient for airway obstruction. Which signs indicate airway compromise? (Select all that apply.)
A PACU nurse is monitoring a patient for airway obstruction. Which signs indicate airway compromise? (Select all that apply.)
A PACU nurse is monitoring a patient at risk for hypovolemic shock. Which findings indicate worsening condition? (Select all that apply.)
A PACU nurse is monitoring a patient at risk for hypovolemic shock. Which findings indicate worsening condition? (Select all that apply.)
A nurse is educating a PACU patient about discharge criteria. What must be met before discharge? (Select all that apply.)
A nurse is educating a PACU patient about discharge criteria. What must be met before discharge? (Select all that apply.)
Which interventions help prevent post-op deep vein thrombosis (DVT)? (Select all that apply.)
Which interventions help prevent post-op deep vein thrombosis (DVT)? (Select all that apply.)
A PACU nurse is managing a patient with nausea and vomiting. Which nursing actions are appropriate? (Select all that apply.)
A PACU nurse is managing a patient with nausea and vomiting. Which nursing actions are appropriate? (Select all that apply.)
Flashcards
Jaw thrust maneuver
Jaw thrust maneuver
Preferred technique to open the airway in an unconscious patient without manipulating the cervical spine.
Opioid-induced respiratory depression
Opioid-induced respiratory depression
Respiratory depression caused by opioids, leading to decreased respiratory rate and oxygen saturation.
Aldrete Score
Aldrete Score
A scoring system used to assess a patient's readiness for discharge from the PACU, evaluating consciousness, respiration, circulation, oxygenation, and activity.
Lateral recovery position
Lateral recovery position
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Hemorrhage
Hemorrhage
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Delayed Emergence
Delayed Emergence
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Meperidine (Demerol)
Meperidine (Demerol)
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Non-verbal signs of pain
Non-verbal signs of pain
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Hypovolemia/Hemorrhage
Hypovolemia/Hemorrhage
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Epidural analgesia and IV opioid titration
Epidural analgesia and IV opioid titration
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Study Notes
- The role of the nurse in the Post-Anesthesia Care Unit (PACU) is tested in the following quiz
Airway Obstruction
- The priority nursing intervention for a post-operative PACU patient exhibiting airway obstruction (stridor, decreased oxygen saturation) is performing a jaw thrust maneuver
- The jaw thrust maneuver is the preferred technique to open the airway in an unconscious patient without manipulating the cervical spine
- Airway obstruction is a priority concern in PACU
Respiratory Depression
- A respiratory rate of 8 breaths/min and low O2 saturation (88%) in a post-op patient who received general anesthesia suggests opioid-induced respiratory depression
- Administer Naloxone, an opioid antagonist, to reverse the effects
Aldrete Score
- An Aldrete Score of 9 or higher is generally required before PACU discharge
- The Aldrete score ensures adequate consciousness, respiration, circulation, oxygenation, and activity
Lateral Recovery Position
- The lateral recovery position helps prevent airway obstruction and aspiration, particularly for patients recovering from anesthesia
Hemorrhage
- If a post-op patient reports severe pain at the surgical site, in addition to hypotension and tachycardia, the priority nursing action is to assess the surgical site for hemorrhage
- Hypotension and tachycardia could indicate hemorrhage, a life-threatening complication that should be assessed immediately
Delayed Emergence
- Findings that indicate a delayed emergence from anesthesia include:
- Unresponsiveness to verbal commands
- Absent or sluggish pupil response
- Hypothermia
- Delayed emergence can be caused by residual anesthetics, hypothermia, or metabolic disturbances
Postoperative Hypothermia
- Nursing interventions that help prevent postoperative hypothermia include:
- Applying warm blankets
- Administering meperidine (Demerol)
- Using a forced-air warming device
- Warming blankets and forced-air warming devices prevent hypothermia
- Meperidine reduces post-anesthesia shivering
Postoperative Nausea and Vomiting
- Interventions that are appropriate for a post-op patient reporting nausea and vomiting in the PACU include:
- Administering ondansetron (Zofran)
- Placing the patient in a lateral position
- Administering 0.9% NS IV fluids
- Ondansetron, lateral positioning, and IV fluids help manage post-op nausea/vomiting (PONV)
- Oral intake should be resumed cautiously
Circulatory Complications
- Findings that require immediate intervention when monitoring a post-op patient for circulatory complications include:
- Delayed capillary refill (> 3 seconds)
- Low urine output (50 mL over 4 hours)
- Hypotension (BP 88/50 mmHg)
- Tachycardia (Heart rate of 120 bpm)
- Delayed capillary refill, low urine output, hypotension, and tachycardia suggest hypovolemia or hemorrhage, requiring immediate intervention
Post-op Pain Management
- Correct statements regarding post-op pain management:
- Elderly patients may require lower opioid doses initially
- Epidural analgesia can be used for post-op pain control
- IV opioids should be titrated based on the patient's response
- Elderly patients often require lower doses initially due to altered metabolism
- Epidural analgesia and IV opioid titration are key pain management strategies
Fluid Resuscitation
- For a post-op patient in the PACU with a blood pressure of 85/50 mmHg, heart rate of 125 bpm, and cool, clammy skin, the priority intervention is administering IV fluids as ordered
- Hypotension and tachycardia indicate hypovolemia or hemorrhage
- Fluid resuscitation is the priority intervention to restore perfusion
Post-Anesthesia Shivering
- Post-anesthesia shivering (PAS) is managed with meperidine, which reduces the body's shivering response
Inadequate Pain Control
- Assessment findings that indicate inadequate pain control include facial grimacing, restlessness, and tachycardia
- Non-verbal signs such as grimacing, restlessness, and tachycardia indicate unrelieved pain
Hypoxia/Airway Obstruction
- Restlessness is an early sign of hypoxia and airway obstruction
- Cyanosis is a late finding
Allergic Reaction
- If a patient in the PACU suddenly develops wheezing, hypotension, and facial swelling after receiving IV antibiotics, the nurse's first action is to stop the antibiotic infusion
- The priority is to stop the causative agent to prevent further anaphylaxis progression
- Epinephrine and oxygen should follow
Risk Factors for Postoperative Nausea and Vomiting
- Young females, a history of motion sickness, and laparoscopic procedures increase PONV risk
PACU Discharge Criteria
- Discharge criteria include spontaneous movement, stable vitals, and adequate oxygenation
Surgical Dressing Assessment
- Excessive bright red blood may indicate hemorrhage and requires urgent intervention when assessing a patient's surgical dressing
Adverse Effects of Opioids
- Opioids can cause respiratory depression and urinary retention, requiring close monitoring
Pain Management in Older Adults
- Older adults metabolize opioids slower initially but may require more meds as tolerance builds
Signs of Airway Compromise
- Signs that indicate airway compromise in a patient being monitored for airway obstruction include:
- Snoring
- Use of accessory muscles
- Cyanosis
- Restlessness
Symptoms of Worsening Hypovolemic Shock
- Findings that indicate worsening condition hypovolemic shock include:
- Blood pressure 80/40 mmHg
- Heart rate 130 bpm
- Urine output 20 mL/hr
- Altered mental status
- Hypotension, tachycardia, low urine output, and confusion are signs of hypovolemic shock
PACU Discharge Criteria
- PACU discharge requires:
- SpO2 ≥ 92% on room air
- Stable vital signs
- Adequate pain control
- Patients must have stable vitals, good oxygenation, pain control, and no dizziness before discharge
Preventing Post-op Deep Vein Thrombosis
- Interventions to help prevent post-op deep vein thrombosis (DVT) include:
- Early ambulation
- Applying sequential compression devices (SCDs)
- Encouraging leg exercises
- Administering low-dose heparin as prescribed
- Ambulation, SCDs, leg exercises, and anticoagulants help prevent DVT
Nursing Actions to Manage Nausea and Vomiting
- Appropriate nursing actions when managing a patient with nausea and vomiting include:
- Administering ondansetron as prescribed
- Keeping the patient NPO
- Positioning the patient laterally
- Encouraging deep breathing exercises
- Ondansetron, NPO status, lateral positioning, and deep breathing help manage PONV
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