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 D

Explanation

A. Ask a family member to take care of it. This is a reasonable option, but if a family member cannot be located, other procedures should be followed to secure the ring.

B. Tape it in place on his finger. Taping the ring on the finger is not advisable as it could create a risk of injury during the surgery and would not be secure. Rings should typically be removed or securely stored.

C. Inform him that the hospital cannot be responsible for its loss. While the hospital cannot be responsible for the loss of personal items, this does not address the need to remove or secure the ring before surgery for safety reasons.

D. Remind him it must be removed, and lock it in the narcotic cabinet. This is the most appropriate action. Jewelry should be removed prior to surgery to avoid injury, and it can be safely stored in a secure location such as the narcotic cabinet or a personal locker.

A. spray the surgical area with an antimicrobial solution. B. shave the entire surgical site. C. scrub the surgical area for 1 minute with antibacterial solution. D. instruct the patient in the use of an antimicrobial soap in the shower.

Correct Answer is A

Explanation

A. Spray the surgical area with an antimicrobial solution. Spraying an antimicrobial solution on the surgical area is a common method of skin preparation to reduce the risk of infection during surgery. It is important to follow specific guidelines set by the facility or surgical team.

B. Shave the entire surgical site. Shaving the surgical site is not typically recommended anymore because it can cause micro-abrasions that increase the risk of infection. Hair clipping is preferred if hair removal is necessary.

C. Scrub the surgical area for 1 minute with antibacterial solution. Scrubbing the area with an antibacterial solution may be part of the preparation, but it is typically done by the surgical team or after following specific guidelines for cleaning, not as a general preoperative action.

D. Instruct the patient in the use of an antimicrobial soap in the shower. This is another common preoperative practice, but the nurse's role may be to instruct the patient rather than carry out the preparation directly.

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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

While completing the preoperative checklist, a patient who is almost ready for transport to the operating room states that he does not want to remove his wedding band. The nurse should:

Correct Answer is D

Explanation

A patient scheduled for surgery has an order for a preoperative surgical skin preparation. The nurse may be required to:

Correct Answer is A

Explanation

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