A nurse cares for a postoperative patient in the PACU. Upon assessment, the nurse finds the surgical dressing is saturated with serosanguineous drainage. Which two interventions are a priority? Select all that apply

Notify surgeon.

Maintain the intravenous fluid infusion.

Provide 2 L/min of oxygen via nasal cannula.

Monitor the patient’s vital signs every 5 to 10 minutes.

Reinforce the dressing.

Answer and Explanation

Correct Answer : A,E

A saturated postoperative dressing with serosanguineous output and physiologic signs of compromise suggests active bleeding and evolving hypovolemia. Timely, systematic interventions can prevent progression to shock.

Rationale for correct answers:

1. Notify surgeon: Saturated dressing may indicate active bleeding; the surgeon must be informed immediately for orders (return to OR, exploratory measures) or further directives.

5. Reinforce the dressing: If a dressing is saturated, do not remove it (removing may disrupt clot); reinforce with additional sterile dressings and apply gentle pressure as ordered to help control external bleeding while arranging definitive care.

Rationale for incorrect answers:

2. Maintain the IV fluid infusion: Maintaining or increasing IV access/fluids preserves venous access for volume resuscitation or blood transfusion and helps stabilize hemodynamics while interventions are arranged.

4. Monitor the patient’s vital signs every 5 to 10 minutes: Frequent vital-sign monitoring detects hemodynamic deterioration early (tachycardia, hypotension, rising respiratory rate) and guides resuscitation decisions.

3. Provide 2 L/min oxygen via nasal cannula: Oxygen may be helpful if the patient shows hypoxia, but it does not stop bleeding or replace lost volume. It’s supportive care and not the highest-priority immediate action when active bleeding is suspected.

Take home points:

Treat increasing wound drainage and hemodynamic changes as potential hemorrhage.
Do not remove a saturated dressing unless specifically ordered.
Reinforce over it and apply pressure; removing it may worsen bleeding and dislodge clots.

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Correct Answer is C

Explanation

Postoperative gas pain commonly results from anesthetic effects, decreased bowel motility, swallowed air, and manipulation of the bowel. Promoting early and frequent ambulation, position changes, and encouraging passing flatus are the most effective nonpharmacologic measures.

Rationale for correct answer:

3. Encourage frequent ambulation: Ambulation stimulates intestinal motility and helps move trapped gas, reducing distention and discomfort. It’s a first-line, low-risk intervention.

Rationale for incorrect answers:

1. Cough and deep breathe every 2 hours: Coughing and deep breathing primarily prevent pulmonary complications (atelectasis) and do not directly relieve intestinal gas.

2. Maintain NPO status for 48 hours: Prolonged NPO is unnecessary for routine gas pain and may delay return of bowel function; early oral intake as tolerated and activity often help.

4. Take vital signs every 4 hours: Monitoring vitals is important for overall postop care but will not directly relieve gas pain.

Take home points:

Early ambulation is the single most effective nursing intervention to relieve postoperative gas pain by stimulating bowel motility.
Use multimodal measures - positioning, ambulation, analgesia to allow activity, and ordered medications such as simethicone.

A. Documenting assessment findings in the medical record B. Using a standardized SBAR tool C. Being responsive in using nonverbal communication techniques D. Giving specific information to a transport technician E. Listening to the OR nurse’s questions

Correct Answer is ["B","C","E"]

Explanation

Effective handoff communication reduces errors and ensures continuity of care. Tools like SBAR, active listening, and nonverbal cues are evidence-based methods to enhance safety in the perioperative setting.

Rationale for correct answers:

2.Using a standardized SBAR tool: SBAR (Situation, Background, Assessment, Recommendation) provides a structured, concise, and effective method for handoff communication, reducing errors.

3. Being responsive in using nonverbal communication techniques: Nonverbal cues such as nodding, eye contact, and attentiveness enhance understanding and ensure the receiver interprets the message accurately.

5. Listening to the OR nurse’s questions: Active listening ensures clarification, avoids misinterpretation, and allows for questions about critical client details.

Rationale for incorrect answers:

1.Documenting assessment findings in the medical record: Documentation is essential but does not ensure direct communication between nurses in different areas. Timely, verbal handoff is more effective for safe surgical care.

4. Giving specific information to a transport technician: Transport staff are not responsible for clinical handoff. Critical pre-op details must be directly communicated nurse-to-nurse.

Take home points:

SBAR and active listening are gold standards for safe handoffs.
Direct communication between responsible nurses is essential; documentation or delegation alone is not sufficient.

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A nurse cares for a postoperative patient in the PACU. Upon assessment, the nurse finds the surgical dressing is saturated with serosanguineous drainage. Which two interventions are a priority? Select all that apply

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Naxlex Comprehensive Predictor Exams

Gas pains are a common postoperative discomfort. Which of the following nursing actions implemented in the plan of care would be most likely to relieve gas pains?

Correct Answer is C

Explanation

Communication between a nurse caring for a patient in the preoperative holding area and the circulating nurse in the operating room (OR) can best be enhanced by which of the following? Select all that apply

Correct Answer is ["B","C","E"]

Explanation

A patient asks a nurse what a PCA pump does. The nurse explains that a PCA pump allows postoperative patients to:

A nurse cares for a postoperative patient in the PACU. Upon assessment, the nurse finds the surgical dressing is saturated with serosanguineous drainage. Which two interventions are a priority? Select all that apply

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