A registered nurse working in a PACU (post-anesthesia-care-unit) is responsible for conducting assessments on immediate post-operative clients.
What is the purpose of these assessments?
To use intra-operative data as a baseline for patient outcome comparison.
To prevent complications from anesthesia and surgery, and to monitor and stabilize the patient they are caring for post-anesthesia.
To focus on cardiovascular data and findings for future cases.
To determine and report the length of time each patient recovers from anesthesia.
The Correct Answer is B
Choice A rationale:
While comparing intra-operative data to post-operative outcomes can be valuable for research and quality improvement purposes, it's not the primary purpose of immediate post-operative assessments in the PACU.
The focus in the PACU is on the patient's immediate well-being and stabilization, not on long-term data analysis.
Choice B rationale:
Preventing complications:
Early detection of potential complications is crucial for timely intervention and prevention of adverse events.
Assessments identify changes in vital signs, respiratory status, pain levels, level of consciousness, surgical site integrity, and other indicators of potential complications.
Monitoring and stabilizing the patient:
Nurses closely monitor patients' physiological responses to anesthesia and surgery, ensuring vital signs remain within acceptable ranges and managing any deviations.
They assess pain levels and administer analgesics as needed, promote respiratory function, maintain fluid and electrolyte balance, and address any other post-operative concerns.
Choice C rationale:
While cardiovascular data is indeed crucial in the PACU, it's not the sole focus of assessments.
Nurses assess a comprehensive range of body systems to ensure overall patient stability and recovery.
Choice D rationale:
Determining recovery time is important, but it's secondary to ensuring patient safety and stability.
Assessments prioritize identifying and addressing potential complications, promoting recovery, and ensuring a safe transition from the PACU.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Administering pre-operative medications does not address the client's expressed desire regarding resuscitation. It is a necessary step in preparing the client for surgery, but it does not directly relate to their preferences for end-of-life care.
Fulfilling this task does not ensure that the client's wishes are communicated to the appropriate healthcare providers, potentially leading to unwanted resuscitative efforts if the client's condition deteriorates during surgery.
It is crucial for the nurse to prioritize the client's autonomy and right to self-determination regarding their healthcare choices.
Choice B rationale:
Informing the physician after the surgery is complete is not timely and could result in the client's wishes not being respected.
The physician needs to be aware of the client's resuscitation preferences before the procedure begins to ensure that care aligns with their wishes.
Delaying communication could lead to ethical and legal dilemmas if resuscitation is attempted against the client's expressed desires.
Choice C rationale:
This is the most appropriate action because it directly addresses the client's concerns and ensures that their wishes are documented and communicated effectively.
Having a clear conversation with the client allows for exploration of their understanding of resuscitation and any potential concerns or questions they may have.
Recording the client's wishes in their medical record provides a clear record for all healthcare providers involved in their care, promoting consistency and respect for their autonomy.
Choice D rationale:
While verbally communicating the client's wishes to the operating room supervisor is important, it is not sufficient on its own.
Written documentation in the medical record is essential to ensure that the information is accurately conveyed to all members of the healthcare team and accessible throughout the client's care journey.
Correct Answer is A
Explanation
Urinary retention is the inability to completely empty the bladder. It is a common symptom of BPH, as the enlarged prostate can press on the urethra and obstruct the flow of urine. This can lead to several characteristic symptoms, including:
Feeling of incomplete bladder emptying: Patients often feel as though they haven't fully emptied their bladder, even after urinating.
Straining to urinate: It may take extra effort to initiate and maintain a urine stream.
Weak urine stream: The force of the urine stream may be noticeably reduced.
Intermittent urine stream: The flow of urine may start and stop repeatedly.
Post-void dribbling: Urine may continue to drip after urination has seemingly ended.
Urinary frequency: The need to urinate frequently, often at night (nocturia).
Urgency: A sudden, compelling need to urinate that may be difficult to postpone.
Bladder pain or discomfort: Pressure or pain in the lower abdomen, often associated with a full bladder. Pathophysiology:
Bladder outlet obstruction: The enlarged prostate physically compresses the urethra, the tube that carries urine from the bladder to the outside of the body. This obstruction makes it difficult for urine to flow freely, leading to incomplete bladder emptying.
Detrusor muscle dysfunction: The detrusor muscle, which forms the bladder wall, may become weakened or overactive due to the constant strain of trying to empty against resistance. This can further impair bladder emptying.
Neurological factors: In some cases, nerve damage or dysfunction may contribute to urinary retention, particularly in men with diabetes or neurological conditions.
Additional insights:
Chronic urinary retention can result in serious complications, such as bladder stones, urinary tract infections, and kidney damage.
Acute urinary retention is a medical emergency that requires immediate catheterization to relieve the bladder and prevent further complications.
Treatment for urinary retention typically involves medications to relax the prostate and bladder muscles, as well as lifestyle modifications such as limiting fluid intake before bedtime. In some cases, surgical intervention may be necessary to reduce the size of the prostate or widen the urethra.
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