A patient who had surgery earlier in the day using general anesthesia asks whether he can have something to eat. The diet order indicates clear liquids can be taken. Before giving a Jell O to the patient, the nurse should check for the presence of:

A. Observe the amount of drainage from the surgical site. While the nurse in the PACU should monitor for complications, the primary focus is on the patient’s immediate recovery, such as airway management and vital signs. Drainage is important but is usually addressed once the patient is stable.

B. Assist the patient to maintain a patent airway. The primary role in the PACU is to monitor and maintain the patient’s airway. Ensuring that the patient is breathing properly is the most critical priority immediately postoperatively.

C. Keep the family posted on the patient's condition. While family communication is important, it is not the primary function of the nurse in the PACU, as the focus should be on monitoring the patient’s immediate condition post-surgery.

D. Maintain safety for the patient while unconscious. The nurse in the PACU must ensure that the patient is safe while unconscious, including monitoring for complications from anesthesia and ensuring that the patient’s vital signs remain stable.

E. Stimulate the patient to hasten return of consciousness. While it is important to help the patient regain consciousness, this should be done gently. The nurse should not aggressively stimulate the patient, as anesthesia will wear off naturally over time.

A. Change the surgical dressing immediately to prevent infection. Changing the dressing immediately is unnecessary unless there is a significant issue, such as excessive drainage or signs of infection. Minor drainage can be observed unless there's a need for further intervention.

B. Outline the area of drainage with a pen and mark it with the date and time. This is the correct action to monitor the drainage over time. By marking the area, the nurse can track whether the drainage increases, stays the same, or decreases, which helps in assessing the wound’s status and effectiveness of the surgical dressing.

C. Make a note of the drainage on the worksheet to report it at the end of shift. While documentation is important, it is essential to monitor the drainage immediately after the initial assessment rather than waiting until the end of the shift.

D. Reinforce the dressing with clean gauze sponges and tape. Reinforcing the dressing may be appropriate if drainage is increasing or if the dressing is inadequate, but marking the area first is necessary for accurate tracking.