A nurse is monitoring the urinary drainage from a patient who returned to the unit a few hours ago from the post anesthesia care unit (PACU) following a surgical procedure. The urine total is 54 mL for the last 2 hours. The most appropriate nursing action is to:

irrigate the indwelling urinary catheter.

notify the surgeon of the findings.

increase the flow rate of the IV for 10 to 15 minutes.

apply manual pressure to the patient's bladder.

Answer and Explanation

The Correct Answer is B

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

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Correct Answer is D

Explanation

A. Artificial body part. This describes a prosthesis, not an elective procedure.

B. Own, originating within an individual. This describes something intrinsic, such as idiopathic conditions, not elective surgery.

C. To relieve pain or complication without curing. This describes palliative care, not an elective procedure.

D. Voluntary. Elective procedures are planned in advance and performed at the patient’s choice rather than as an emergency (e.g., cosmetic surgery, knee replacement).

A. observe the amount of drainage from the surgical site. B. assist the patient to maintain a patent airway. C. keep the family posted on the patient's condition. D. maintain safety for the patient while unconscious. E. stimulate the patient to hasten return of consciousness.

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.

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A nurse is monitoring the urinary drainage from a patient who returned to the unit a few hours ago from the post anesthesia care unit (PACU) following a surgical procedure. The urine total is 54 mL for the last 2 hours. The most appropriate nursing action is to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is the meaning of the following term: elective

Correct Answer is D

Explanation

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

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