When a patient arrives in the PACU with a surgical dressing, an intravenous infusion, and a urinary catheter, the priority action of the nurse is assessment of:
IV line patency
urine output
airway patency
wound drainage
None
None
The Correct Answer is C
A. IV line patency: IV access is important for fluid and medication administration, but it is not the highest priority immediately postoperatively.
B. Urine output: Monitoring urine output is important for assessing kidney function and fluid balance, but airway management takes precedence.
C. Airway patency: The priority in the immediate postoperative period is maintaining a patent airway, as patients are at risk for respiratory complications such as obstruction, hypoxia, and aspiration due to anesthesia effects.
D. Wound drainage: Assessing wound drainage is necessary to monitor for excessive bleeding or infection, but it is not the top priority compared to airway patency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Are communications links with personnel outside the room. Both the scrub person and the circulating nurse serve as communication links with the personnel outside the operating room. The scrub person may communicate regarding sterile equipment needs, while the circulating nurse communicates about patient status and surgical progress.
B. Set up initial sterile instruments and supplies. This is the responsibility of the scrub person, not the circulating nurse. The scrub person ensures that sterile instruments are ready and that the sterile field is set up properly.
C. Advise the team of breaks in sterile technique. Only the scrub person is typically responsible for maintaining sterile technique and calling attention to any breaches in sterility. The circulating nurse may assist with ensuring the environment is safe, but the scrub person is directly in charge of sterile technique.
D. Position lights on step stools. Positioning the lights is the responsibility of the circulating nurse. The scrub person’s role is more focused on the sterile field and assisting with surgical instruments.
Correct Answer is B
Explanation
A. Irrigate the indwelling urinary catheter. There is no indication that the catheter is obstructed. Catheter irrigation should only be performed if there is a suspected blockage (e.g., absent urine output, blood clots).
B. Notify the surgeon of the findings. Urine output of less than 30 mL per hour is concerning for decreased renal perfusion, possibly due to hypovolemia or other postoperative complications. The provider should be notified for further evaluation and intervention.
C. Increase the flow rate of the IV for 10 to 15 minutes. Increasing IV fluids may help improve urine output, but it should only be done based on a provider’s order and after assessing the patient’s volume status.
D. Apply manual pressure to the patient's bladder. This action is inappropriate unless the patient has urinary retention, which should be confirmed through assessment before attempting bladder compression
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.