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10 Cards in this Set
- Front
- Back
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What are the three phases of PACU?
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1. Phase I
2. Phase II 3. Extended Observation |
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During the pt's admission to the PACU, what are the priority interventions the nurse performs?
a. assess the surgical site, noting presence and character of drainage b. assess the amount of urinary output and the presence of bladder distention c. assess for airway patency and quality of respirations and obtain VS d. review results of intraoperative laboratory values and medications received. |
c. assess for airway patency and quality of respirations and obtain VS
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A pt admitted to the PACU following major abdominal surgery. During the initial assessment, the pt tells the nurse he thinks he is going to "throw up" A priority nursing intervention would be to
a. obtain VS including O2 saturation b. position pt in lateral recovery position c. administer antiemetic medication as ordered d. apply intermittent compression devices (ICD's) |
b. position pt in lateral recovery position
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Following admission of the postoperative pt to the clinical unit, which of the following assessment data requires the most immediate attention?
a. O2 of 85% b. RR 13 c. Temperature of 38 (100.4) d. BP of 90/60 |
a. O2 of 85%
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A postoperative patient is transferred from the postanesthesia unit to the medical-surgical nursing floor. The nurse notes that the patient has an order for D5½ NS to infuse at 125 ml/hr. Until an IV pump is available, the nurse regulates the IV flow rate at which of the following drops (gtts)/min, noting that the tubing has a drop factor of 10 drops/ml?
A) 13 gtts/min B) 31 gtts/min C) 25 gtts/min D) 21 gtts/min |
D) 21 gtts/min
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The nurse is preparing to administer cefazolin (Ancef) 2 gm in 100 ml of normal saline to a postoperative patient. Which of the following IV rates will infuse this medication over 20 minutes?
A) 100 ml/hr B) 150 ml/hr C) 200 ml/hr D) 300 ml/hr |
D) 300 ml/hr
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The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia unit. Which of the following should be the nurse’s initial action upon the patient’s arrival?
A) Assess the patient’s pain. B) Assess the patient’s vital signs. C) Check the rate of the IV infusion. D) Check the physician’s postoperative orders. |
B) Assess the patient’s vital signs.
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When assessing a patient’s surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. In response to this finding, the nurse should do which of the following?
A) Recheck in 1 hour for increased drainage. B) Notify the surgeon of a potential hemorrhage. C) Assess the patient’s blood pressure and heart rate. D) Remove the dressing and assess the surgical incision. |
C) Assess the patient’s blood pressure and heart rate.
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In planning postoperative interventions to promote ambulation, coughing, deep breathing, and turning, the nurse recognizes that which of the following actions will best enable the patient to achieve the desired outcomes?
A) Administering adequate analgesics to promote relief or control of pain B) Asking the patient to demonstrate the postoperative exercises every 1 hour C) Giving the patient positive feedback when the activities are performed correctly D) Warning the patient about possible complications if the activities are not performed |
A) Administering adequate analgesics to promote relief or control of pain
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Bronchial obstruction by retained secretions has contributed to a postoperative patient’s recent pulse oximetry reading of 87%. Which of the following health problems is the patient experiencing?
A) Atelectasis B) Bronchospasm C) Hypoventilation D) Pulmonary embolism |
A) Atelectasis
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