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Which is the priority intervention for the nurse to perform in the post anesthesia care unit (PACU)?

Assess the surgical dressing, noting presence and character of drainage.

Assess urinary output and presence of bladder distention.

Assess blood pressure and the estimated blood loss during surgery.

Assess for airway patency and quality of respirations.

Answer and Explanation

The Correct Answer is D

A. Checking the surgical dressing is important but not as urgent as ensuring respiratory function.

B. Assessing urinary output is necessary but secondary to airway patency.

C. Monitoring blood pressure and blood loss is important but less critical than respiratory status.

D. Airway patency is the highest priority in the immediate postoperative period to prevent respiratory failure.

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Correct Answer is D

Explanation

A. While calming, this response does not acknowledge the client’s concerns.

B. This statement may discourage the client and increase anxiety.

C. This response is dismissive and assumes that discussing concerns will eliminate nervousness.

D. Encouraging the client to verbalize concerns fosters trust and allows the nurse to address specific fears.

A. Discuss alternatives to the procedure. B. Inform the provider that the client is withdrawing consent C. Explain why this procedure is necessary. D. Remind the client the consent form has already has been signed.

Correct Answer is B

Explanation

A. While discussing alternatives may be beneficial later, it is not the priority action when consent is withdrawn.

B. Informing the provider ensures the client’s right to withdraw consent is respected and initiates appropriate communication.

C. Explaining why the procedure is necessary may feel coercive and does not prioritize the client’s autonomy.

D. Reminding the client about the signed consent form undermines their right to change their decision.

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Which is the priority intervention for the nurse to perform in the post anesthesia care unit (PACU)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing preoperative teaching. The client states, "I'm so nervous about my surgery". What is the best response by the nurse?

Correct Answer is D

Explanation

A nurse is caring for a client who has provided informed consent in preparation for a procedure. The client states, "I have decided not to have the procedure." Which action should the nurse take?

Correct Answer is B

Explanation

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