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

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

Explanation

A. Change the surgical dressing immediately to prevent infection. Changing the dressing immediately is unnecessary unless there is a significant issue, such as excessive drainage or signs of infection. Minor drainage can be observed unless there's a need for further intervention.

B. Outline the area of drainage with a pen and mark it with the date and time. This is the correct action to monitor the drainage over time. By marking the area, the nurse can track whether the drainage increases, stays the same, or decreases, which helps in assessing the wound’s status and effectiveness of the surgical dressing.

C. Make a note of the drainage on the worksheet to report it at the end of shift. While documentation is important, it is essential to monitor the drainage immediately after the initial assessment rather than waiting until the end of the shift.

D. Reinforce the dressing with clean gauze sponges and tape. Reinforcing the dressing may be appropriate if drainage is increasing or if the dressing is inadequate, but marking the area first is necessary for accurate tracking.

A. allow the patient to be taken to surgery after notifying the circulating nurse. B. inform the surgeon of the error. C. request a corrected consent form to be signed. D. have the new form attached to the old incorrect one and document it.

Correct Answer is C

Explanation

A. Allow the patient to be taken to surgery after notifying the circulating nurse. The patient should not proceed to surgery with an incorrect name on the consent form, even if the circulating nurse is informed.

B. Inform the surgeon of the error. While notifying the surgeon is important, the primary action is to obtain a corrected consent form.

C. Request a corrected consent form to be signed. A surgical consent form must be accurate. A new, correctly spelled form should be obtained before surgery to ensure legal and ethical compliance.

D. Have the new form attached to the old incorrect one and document it. Attaching a new form does not resolve the error; a corrected and properly signed form is required before surgery proceeds.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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