What are the priority interventions the nurse performs when admitting a patient to the pacu?

Lewis Chapter 19: Postoperative Care

When a patient is admitted to the PACU, what are the priority interventions the nurse performs?
a. Assess the surgical site, no tine presence and character of drainage
b. Assess the amount of urine output and the presence of bladder distention
c. Assess f

c. Assess for airway potency and quality of expirations, and obtain vital signs.
Rationale: Assessment in the postanesthesia care unit (PACU) begins with evaluation of the airway, breathing, and circulation (ABC) status of the patient. Identification of i

A patient is admitted to the PACU after major abdominal surgery. During the initial assessment the patient tells the nurse he thinks he is going to "throw up." A priority nursing intervention would be to:
a. increase the rate of IV fluids
b. obtain vital

c. position patient in lateral recovery position
Rationale: If the patient is nauseated and may vomit, place the patient in a lateral recovery position to keep the airway open and reduce the risk of aspiration if vomiting occurs.

After admission of the postoperative patient to the clinical unit, which assessment data require the most immediate attention?
a. Oxygen saturation of 85%
b. Respiratory rate of 13/min
c. Temperature of 100.4F
d. Blood pressure of 90/60 mmHg

a. Oxygen saturation of 85%
Rationale: During the initial assessment, identify signs of inadequate oxygenation and ventilation. Pulse oximetry monitoring is initiated because it provides a noninvasive means of assessing the adequacy of oxygenation. Pulse

A 70-kg postoperative patient has an average urine output of 25 mL/hr during the first 8 hours. The priority nursing intervention(s) given this assessment would be to:
a. perform a straight catheterization to measure the amount of urine in the bladder
b.

d. evaluate the patient's fluid volume status since surgery and obtain a bladder ultrasound
Rationale: Because of the possibility of infection associated with catheterization, the nurse should first try to validate that the bladder is full. The nurse shou

Discharge criteria for the Phsae II patient include (select all that apply):
a. no nausea or vomiting
b. ability to drive self home
c. no respiratory depression
d. written discharge instructions understood
e. opioid pain medication given 45 minutes ago

c, d, & e
Rationale: Phase II discharge criteria that must be met include the following: all PACU discharge criteria (Phase I) met; no intravenous opioid drugs administered for the past 30 minutes; patient's ability to void (if appropriate with regard to

Unless contraindicated by the surgical procedure, which position is preferred for the unconscious patient immediately postoperative?
a. Supine
b. Lateral
c. Semi-Fowler's
d. High-Fowler's

b. Lateral
Unless contraindicated by the surgical procedure, the unconscious patient is positioned in a lateral "recovery" position. This recovery position keeps the airway open and reduces the risk of aspiration if the patient vomits. Once conscious, the

The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse's initial action be upon the patient's arrival?
a. Assess the patient's pain.
b. Assess the patien

b. Assess the patient's vital signs.
The highest priority action by the nurse is to assess the physiologic stability of the patient. This is accomplished in part by taking the patient's vital signs. The other actions can then take place in rapid sequence.

When assessing a patient's surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. In response to this finding, what should the nurse do first?
a. Recheck in 1 hour for increased drainage.
b. Noti

c. Assess the patient's blood pressure and heart rate.
The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse can then report all of the findings. Continued reassessment will be done. Agen

In planning postoperative interventions to promote repositioning, ambulation, coughing, and deep breathing, which action should the nurse recognize will best enable the patient to achieve the desired outcomes?
a. Administering adequate analgesics to promo

a. Administering adequate analgesics to promote relief or control of pain
Even when a patient understands the importance of postoperative activities and demonstrates them correctly, it is unlikely that the best outcome will occur unless the patient has su

Bronchial obstruction by retained secretions has contributed to a postoperative patient's recent pulse oximetry reading of 87%. Which health problem is the patient probably experiencing?
a. Atelectasis
b. Bronchospasm
c. Hypoventilation
d. Pulmonary embol

a. Atelectasis
The most common cause of postoperative hypoxemia is atelectasis, which may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion. Bronchospasm involves the closure of small airways by increa

In caring for the postoperative patient on the clinical unit after transfer from the PACU, which care can be delegated to the unlicensed assistive personnel (UAP)?
a. Monitor the patient's pain.
b. Do the admission vital signs.
c. Assist the patient to ta

c. Assist the patient to take deep breaths and cough.
The UAP can encourage and assist the patient to do deep breathing and coughing exercises and report complaints of pain to the nurse caring for the patient. The RN should do the admission vital signs fo

The patient had abdominal surgery. The estimated blood loss was 400 mL. The patient received 300 mL of 0.9% saline during surgery. Postoperatively, the patient is hypotensive. What should the nurse anticipate for this patient?
a. Blood administration
b. R

b. Restoring circulating volume
The nurse should anticipate restoring circulating volume with IV infusion. Although blood could be used to restore circulating volume, there are no manifestations in this patient indicating a need for blood administration.

The patient donated a kidney, and early ambulation is included in her plan of care. But the patient refuses to get up and walk. What rationale should the nurse explain to the patient for early ambulation?
a. "Early walking keeps your legs limber and stron

d. "Early walking is the best way to prevent postoperative complications."
The best rationale is that early ambulation will prevent postoperative complications that can then be discussed. Ambulating increases muscle tone, stimulates circulation that preve

An older patient who had surgery is displaying manifestations of delirium. What should the nurse do first to provide the best care for this new patient?
a. Check his chart for intraoperative complications.
b. Check which medications were used for anesthes

d. Check his preoperative assessment for previous delirium or dementia.
If the patient's ABCs are okay, it is important to first know if the patient was mentally alert without cognitive impairments before surgery. Then intraoperative complications, anesth

The patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge (select all that apply)?
a. Vital signs baseline or stable
b. Minimal nausea and vomiting
c. Wants to go to the bathroom at home
d. Re

a, b, & d
Ambulatory surgery discharge criteria includes meeting Phase I PACU discharge criteria that includes vital signs baseline or stable and minimal nausea and vomiting. Phase II criteria includes a responsible adult driving patient, no IV opioid dru

A patient is having elective cosmetic surgery performed on her face. The surgeon will keep her at the surgery center for 24 hours after surgery. What is the nurse's postoperative priority for this patient?
a. Manage patient pain.
b. Control the bleeding.

d. Manage oxygenation status.
The nurse's priority is to manage the patient's oxygenation status by maintaining an airway and ventilation. With surgery on the face, there may be swelling that could compromise her ability to breathe. Pain, bleeding, and fl

What are the priority nursing interventions for the patient while in the PACU?

What is the priority initial nursing assessment in the PACU?

What is the main focus of care in post operative recovery room?

What are the three phases of PACU?