After the surgery, the patient is transferred to the PACU. Functions of the nurse in the PACU are to

observe the amount of drainage from the surgical site.

assist the patient to maintain a patent airway.

keep the family posted on the patient's condition.

maintain safety for the patient while unconscious.

stimulate the patient to hasten return of consciousness.

Answer and Explanation

Correct Answer : B,D

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.

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Correct Answer is C

Explanation

A. That vomiting might be an expected symptom. Vomiting can occur post-surgery, particularly if anesthesia was used, but this is not an expected or desired symptom. The education plan should focus on advising the patient about managing nausea if it occurs, rather than presenting vomiting as an expected outcome.

B. Limiting wine intake for 12 hours. Alcohol intake should be avoided after surgery, but the specific restriction may vary depending on the procedure and type of anesthesia used. The recommendation is usually to avoid alcohol for at least 24 hours, not just 12 hours. Therefore, this is not an ideal choice for the education plan.

C. Not driving or making important decisions for 24 hours. After same-day surgery, the effects of anesthesia can last for several hours, impairing the patient's cognitive and motor abilities. It is important to educate the patient to avoid driving or making significant decisions for at least 24 hours after surgery to prevent accidents and errors.

D. Reporting temperatures greater than 99°F. A temperature greater than 99°F may not be a significant concern post-surgery. Generally, a fever above 100.4°F (38°C) would be more concerning. The patient should be instructed to report a higher fever, but a temperature of 99°F alone is usually not an alarming sign.

A. Ill and the patient has depressed reflexes. B. IV and the patient will not depend on the anesthesia machine of oxygenations. C. Il and the surgical environment should be kept quiet. D. and the patient's hearing is amplified.

Correct Answer is C

Explanation

A. Stage III and the patient has depressed reflexes. Stage III of anesthesia is the surgical stage, where the patient is under deep anesthesia, and reflexes are typically depressed. However, tensed muscles and irregular respirations may indicate that the patient is still in an earlier stage of anesthesia (stage II).

B. Stage IV and the patient will not depend on the anesthesia machine for oxygenation. Stage IV is the deepest level of anesthesia, where respiratory and cardiovascular functions are severely depressed. It does not match the description of tensed muscles and irregular respirations, which are more characteristic of an earlier stage (stage II).

C. Stage II and the surgical environment should be kept quiet. Stage II of anesthesia is the excitement stage, where patients may exhibit tensed muscles, irregular respirations, and uncoordinated movements. The surgical environment should be kept quiet to minimize stimuli that could cause agitation or further excitement in this stage.

D. Stage I and the patient's hearing is amplified. Stage I is the stage of anesthesia where the patient is still conscious and responsive to stimuli. The description of tensed muscles and irregular respirations does not match this stage. Additionally, the patient’s hearing would not be amplified in stage I, but rather in stage II or as they begin to emerge from anesthesia.

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After the surgery, the patient is transferred to the PACU. Functions of the nurse in the PACU are to

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

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