A nurse assesses a postoperative patient 2 days after chest surgery. What four findings indicate that the patient has inadequate pain control?

Choice A reason:
Assessing the operative site is important to monitor for signs of bleeding, infection, or other complications. However, it is not the most critical, high-priority assessment immediately after surgery. While the condition of the surgical site can provide valuable information about the patient’s recovery and potential complications, it does not take precedence over ensuring the patient’s airway is clear and they are breathing adequately. The operative site can be assessed once the patient’s airway, breathing, and circulation are stable.
Choice B reason:
Airway assessment is the most critical, high-priority assessment in the PACU. Ensuring that the patient’s airway is clear and they are breathing properly is paramount because anesthesia can depress the central nervous system, leading to compromised airway patency and respiratory function. The primary goal in the immediate postoperative period is to ensure that the patient is ventilating adequately to prevent hypoxia and other respiratory complications. This involves checking for airway obstruction, monitoring respiratory rate, and ensuring that oxygen saturation levels are within normal ranges (typically 95-100% for healthy individuals). Any issues with the airway must be addressed immediately to prevent life-threatening complications.
Choice C reason:
Assessing the pulse is crucial for monitoring the patient’s cardiovascular status, including heart rate and rhythm. This can help detect arrhythmias, hypovolemia, or other cardiovascular issues that may arise postoperatively. However, while important, it is secondary to ensuring that the patient’s airway is clear and they are breathing adequately. The pulse can be assessed once the airway and breathing are confirmed to be stable. Normal pulse rates for adults typically range from 60 to 100 beats per minute.
Choice D reason:
Assessing skin integrity is important for identifying signs of pressure ulcers, infection, or other skin-related issues. However, this assessment is not the highest priority immediately after surgery. Ensuring the patient’s airway, breathing, and circulation are stable takes precedence. Skin integrity can be assessed once the patient is stable and other critical assessments have been completed. Maintaining skin integrity is essential for overall patient care, but it does not supersede the need to ensure the patient is breathing properly and has a clear airway.

Choice A: All materials that enter the sterile field must be sterile

This is a correct principle of aseptic technique. Ensuring that all materials entering the sterile field are sterile is fundamental to preventing contamination and infection during surgical procedures. Any non-sterile item introduced into the sterile field can introduce pathogens, compromising patient safety.

Choice B: The surgical team working in the operative field must wear sterile gowns and gloves

This is another correct principle. Members of the surgical team who work directly in the operative field must wear sterile gowns and gloves to create a barrier against microorganisms. This practice helps maintain the sterility of the surgical environment and protects both the patient and the healthcare providers.

Choice C: The sterile package is contaminated once it has been opened

This statement is incorrect. A sterile package is not necessarily contaminated once it has been opened, provided it is opened correctly and the contents are handled using aseptic techniques. Proper opening and handling ensure that the sterility of the contents is maintained.

Choice D: The circulating nurse must wear sterile gowns and gloves

This statement is incorrect. The circulating nurse does not need to wear sterile gowns and gloves because they do not work directly in the sterile field. Instead, they assist by providing necessary supplies and support from outside the sterile area.

Choice E: Tables are sterile only at tabletop level. Items extending beneath this level are contaminated

This is a correct principle. In the operating room, the sterility of tables is maintained only at the tabletop level. Any items that extend below this level are considered contaminated and should not be used in the sterile field.

Choice F: A wide margin of safety is maintained between sterile and unsterile fields

This is also a correct principle. Maintaining a wide margin of safety between sterile and unsterile fields helps prevent accidental contamination. This practice ensures that sterile areas remain uncontaminated by non-sterile items or personnel.