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

Answer and Explanation

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.

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Correct Answer is ["B","D"]

Explanation

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.

A. Start with small sips of water at first to see if they are retained B. Wait until his liquid diet tray arrives at mealtime C. Take in a variety of fluids totaling 3000mls/day D. Go ahead and drink all the water he wants

Correct Answer is A

Explanation

A. Start with small sips of water at first to see if they are retained. Starting with small sips allows the digestive system to adjust gradually, reducing the risk of nausea, vomiting, or complications from overconsumption after surgery.

B. Wait until his liquid diet tray arrives at mealtime. The patient is eager to try fluids, and waiting for the full meal tray may unnecessarily delay the process of reintroducing fluids.

C. Take in a variety of fluids totaling 3000mls/day. The patient should not be expected to consume a large volume of fluid right away; fluid intake should be gradually increased as tolerated.

D. Go ahead and drink all the water he wants. Allowing the patient to drink freely can overwhelm the digestive system and may cause complications, such as nausea or vomiting.

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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:

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is ["B","D"]

Explanation

The second day post-operatively, the NG tube is removed and an order is written for fluids as tolerated and a liquid diet. The patient is eager to try taking fluids. What should the nurse recommend that he do?

Correct Answer is A

Explanation

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