The nurse is aware that in both the very young and the older adult surgical patient, the risk is much higher for:

A. When still conscious, participate in marking the surgical site. The surgical site marking should be done with patient participation before anesthesia to confirm accuracy and prevent wrong-site surgery.

B. Have a photograph of the surgical site in the medical record. Photographs are not a standard requirement for surgical verification.

C. Have the unit nurse confirm their identity. Identity confirmation is necessary but not sufficient to prevent wrong-site surgery. Marking the site is the key step.

D. Verbally state the location of the surgical site and the expected procedure. Verbal confirmation is important but should be combined with physical marking of the site to ensure accuracy.

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.