The PACU nurse is receiving the client from the OR. Which intervention should the nurse implement first?
1. Assess the client's breath sounds.
2. Apply oxygen via nasal cannula.
3. Take the client's blood pressure.
4. Monitor the pulse oximeter reading.
1. Assess the client's breath sounds.
Rationale: The airway should be assessed first. When caring for a client, the nurse should follow the ABC's: airway, breathing, and circulation.
Why it's not the rest: After assessing the client's airway and breathing, the nurse can apply oxygen via a nasal cannula if necessary. The blood pressure is taken automatically by the monitor, but this is not a priority over airway. The pulse oximeter is applied to the client's finger to obtain the peripheral oxygenation status, but the nurse should assess the client's breathing first.
Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia?
1. Loss of sensation at the lumbar (L5) dermatome.
2. Absence of the client's posterior tibial pulse.
3. The client has a respiratory rate of eight (8).
4. The blood pressure is within 20% of the client's baseline.
3. The client has a respiratory rate of eight (8).
Rationale: If the effects of the spinal anesthesia move up rather than down the spinal cord, respirations can be depressed and even blocked.
Why it's not the rest: Loss of sensation in the L5 dermatome is expected from spinal anesthesia. Absence of a posterior tibial pulse is indicative of a block in the blood supply, but is not a complication of the spinal anesthesia. The BP is an expected outcome and does not indicate a complication.
The surgical client's vital signs are T 98'F, P 106, R 24, and BP 88/40. The client is awake and oriented times three (3) and the skin is pale and damp. Which intervention should the nurse implement first?
1. Call the surgeon and report the vital signs.
2. Start an IV of D5RL with 20 mEq KCl at 125 ml/hr.
3. Elevate the feet and lower the head.
4. Monitor the vital signs every 15 minutes.
3. Elevate the feet and lower the head.
Rationale: By lowering the head of the bed and raising the feet, the blood is shunted to the brain until volume-expanding fluids can be administered, which is the first intervention for a client who is hemorrhaging.
Why it's not the rest: The surgeon should be notified, but this is not the first action; the client must be cared for. The postoperative client had lactated Ringer's infused during surgery; the rate should be increased during hemorrhage-which the vital signs indicate is occurring-but potassium should not be added. When signs and symptoms of shock are observed, the nurse will monitor the vital signs more frequently than every 15 minutes.
The PACU nurse administers Narcan, an opioid antagonist, to a postoperative client. Which client problem should the nurse include to the plan of care based on this medication?
1. Alteration in comfort.
2. Risk for depressed respiratory pattern.
3. Potential for infection.
4. Fluid and electrolyte imbalance.
2. Risk for depressed respiratory pattern.
Rationale: A client with respiratory depression treated with Narcan can have another episode within 15 minutes after receiving the drug as a result of the short half-life of the medication.
Why it's not the rest: Narcan does not cause pain for the client. Infection would not be a concern immediately after surgery. Although the client may experience an imbalance in fluid or electrolytes, this problem would not be of concern as a result of the administration of Narcan.
The 26-year-old male client in the PACU has a heart rate of 110 and a rising temperature and complains of muscle stiffness. Which interventions should the nurse implement? Select all that apply.
1. Give a back rub to the client to relieve stiffness.
2. Apply ice packs to the axillary and groin areas.
3. Prepare an ice slush for the client to drink.
4. Prepare to administer dantrolene, a smooth muscle relaxant.
5.
Reposition the client on a warming blanket.
2. Apply ice packs to the axillary and groin areas.
4. Prepare to administer dantrolene, a smooth muscle relaxant.
Rationale: Ice packs should be applied to the axillary and groin areas for a client experiencing malignant hyperthermia. Dantrolene is the drug of choice for treatment.
Why it's not the rest: A back rub is a therapeutic intervention, but it is not appropriate for a life-threatening complication of surgery. The client would be NPO to prepare for intubation, but an ice slush would be used to irrigate the bladder and stomach per nasogastric tube. Cooling blankets, not warming blankets, are used to decrease the fast-rising temperature.
Which data indicate to the nurse the client who is one (1) day postoperative right total hip replacement is progressing as expected?
1. Urine output was 160 mL in the past eight (8)
hours.
2. Paralysis and paresthesia of the right leg.
3. T 99.0'F, P 98, R 20, and BP 100/60.
4. Lungs are clear bilaterally in all lobes.
4. Lungs are clear bilaterally in all lobes.
Rationale: Lung sounds which are clear bilaterally in all lobes indicate the client has adequate gas exchange, which prevents postoperative complications and indicates effective nursing care.
Why it's not the rest: Adequate urine output should be 30 mL/hr or at least 240 mL in an eight (8)-hour period. Paralysis (inability to move) and paresthesia (numbness and tingling) indicate neurovascular compromise to the right leg, which indicates a complication and is not an expected outcome. The client's temperature and pulse are slightly elevated, and the BP is low, which does not indicate effective nursing care.
The nurse and the unlicensed assistive personnel (UAP) are working on a surgical unit. Which task can the nurse delegate to the UAP?
1. Take routine vital signs on clients.
2. Check the Jackson Pratt insertion site.
3. Hang the client's next IV bag.
4. Ensure the client obtains pain relief.
1. Take routine vital signs on clients.
Rationale: Taking the vital signs of the stable client may be delegated to the UAP.
Why it's not the rest: Assessments cannot be delegated; "check" is a word which means "to assess." IV's cannot be hung by the UAP; this is considered administering a medication. Evaluating the client's pain relief is a responsibility of the RN.
The charge nurse is making shift assignments. Which postoperative client should be assigned to the most experienced nurse?
1. The 4-year-old who had a tonsillectomy and is able to swallow fluids.
2. The 74-year-old client with a repair of the left hip who is unable to ambulate.
3. The 24-year-old client who
had an uncomplicated appendectomy the previous day.
4. The 80-year-old client with a small bowel obstruction and congestive heart failure.
4. The 80-year-old client with a small bowel obstruction and congestive heart failure.
Rationale: An older client with a chronic disease would be a complicated case, requiring the care of a more experienced nurse.
Why it's not the rest: The 4-year-old appears stable; pediatric clients can become unstable quickly, but the most experienced nurse would not need to care for this client. The 74-year-old will be ambulated by the physical therapist and is stable. The 24-year-old would require routine postoperative care.
Which statement would be an expected outcome for the postoperative client who had general anesthesia?
1. The client will be able to sit in the chair for 30 minutes.
2. The client will have a pulse oximetry reading of 97% on room
air.
3. The client will have a urine output of 30 mL per hour.
4. The client will be able to distinguish sharp from dull sensations.
2. The client will have a pulse oximetry reading of 97% on room air.
Rationale: The anesthesia machine takes over the function of the lungs during surgery, so the expected outcome should directly reflect the client's respiratory status; the alveoli can collapse, causing atelectasis.
Why it's not the rest: The postoperative client is expected to be out of bed as soon as possible, but this goal is not specific to having general anesthesia. Urine output should be 30mL/hr, but the expected outcome is not specific to general anesthesia. Sensation would be an outcome assessed after the use of a spinal anesthesia or block, but it is not specific to general anesthesia.
The postoperative client is transferred from the PACU to the surgical floor. Which action should the nurse implement first?
1. Apply antiembolism hose to the client.
2. Attach the drain to 20 cm suction.
3. Assess the client's vital signs.
4. Listen to the report from the anesthesiologist.
3. Assess the client's vital signs.
Rationale: Assessing the client's status after transfer from the PACU should be the nurse's first intervention.
Why it's not the rest: Applying antiembolism hose may be appropriate, but it is not the first intervention. Attaching a drain would be appropriate but not before assessing the client. Receiving reports is not the nurse's first intervention.
Which problem should the nurse identify as priority for client who is one (1) day postoperative?
1. Potential for hemorrhaging.
2. Potential for injury.
3. Potential for fluid volume excess.
4. Potential for infection.
1. Potential for hemorrhaging.
Rationale: All clients who undergo surgery are at risk for hemorrhaging , which is the priority problem.
Why it's not the rest: The client is at risk for injury but the priority problem the first day postoperative is hemorrhaging. A potential fluid imbalance would be for less fluid as a result of blood loss and decreased oral intake; it would not be for fluid volume excess. Infection would be a potential problem but not priority over hemorrhaging on the first postoperative day.
The UAP reports the vital signs for a first-day postoperative client as T 100.8'F, P 80, R 24, and BP 148/80. Which intervention would be most appropriate for the nurse to implement?
1. Administer the antibiotic earlier than scheduled.
2. Change the dressing over the wound.
3. Have the client turn, cough, and deep breathe every two (2) hours.
4. Encourage the client to ambulate in the hall.
3. Have the client turn, cough, and deep breathe every two (2) hours.
Rationale: Having the client turn, cough, and deep breath (TCDB) is the best intervention for the nurse to implement because, if a client has a fever within the first day, it is usually caused by a respiratory problem.
Why it's not the rest: Antibiotics need to be administered at the scheduled time. The data does not support the need for a dressing change, and surgeons usually want to change the surgical dressing for the first time. The client is first-day postoperative, and ambulating in the hall would not be appropriate.