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 D

Explanation

A. Palpable peripheral pulses. Palpable pulses are important for circulatory assessment but are not relevant in determining whether the patient can eat after surgery.

B. Clear lung sounds. Clear lung sounds are important for respiratory status, but they are not the primary factor in determining whether a patient can start clear liquids.

C. Adequate urinary drainage. Urinary drainage is important for monitoring kidney function postoperatively but is not a primary factor in whether a patient can eat clear liquids.

D. Bowel sounds in all quadrants. The presence of bowel sounds indicates that the gastrointestinal system is functioning well enough to begin processing liquids, making this an important assessment before offering fluids or food.

A. Dry crust on the incision line B. Increased urine output C. Decreased level of consciousness D. Adventitious breath sounds E. Oral temperature of 38.3° C (101° F)

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

Explanation

A. Dry crust on the incision line.
Dry crust on the incision line could indicate that the wound is healing well, but it is not typically a sign of infection. Infection is more commonly associated with redness, warmth, and drainage. A dry crust does not automatically suggest infection.

B. Increased urine output.
Increased urine output is generally a sign of good hydration or adequate kidney function, not an indication of infection. Infection would more likely present with a fever or abnormal wound appearance, not increased urine output.

C. Decreased level of consciousness.
A decreased level of consciousness can be a sign of sepsis, an infection that has spread throughout the body. This is a serious indicator of possible infection, especially if it is sudden or unexplained in the postoperative period.

D. Adventitious breath sounds.
Adventitious breath sounds could be a sign of a respiratory infection or complications such as pneumonia, but they are not necessarily linked to infection at the surgical site. If the sounds are related to infection, this could be a sign of a lower respiratory tract infection.

E. Oral temperature of 38.3° C (101° F).
An oral temperature of 38.3° C (101° F) is a fever, which is a classic sign of infection. Fever is a common early sign of infection in the postoperative period and should be promptly addressed to rule out surgical site infection or other complications.

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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

Explanation

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