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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 B

Explanation

A. Assuming the client’s decision is based on fear may feel dismissive of their beliefs.

B. Acknowledging and respecting the client’s decision while confirming their right to consent honors their autonomy and builds trust.

C. Questioning the client’s decision undermines their beliefs and autonomy.

D. Reassuring the client about blood loss dismisses their valid concerns about transfusion refusal.

A. “I have the ability to self-dose when experience pain." B. “I can receive a dose as often as need with this pump.” C. “I’ll receive a steady flow of medication to control my pain.” D. "I will decide with the nurse when I should receive a dose."

Correct Answer is A

Explanation

A. PCA pumps allow clients to self-administer pain medication within prescribed limits when experiencing pain.

B. Doses are controlled by a lockout mechanism to prevent overdosing.

C. PCA pumps deliver medication as needed, not a continuous infusion unless programmed otherwise.

D. The client independently determines when to use the PCA within prescribed parameters.

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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

During a pre-surgical admission assessment, a client states. "I've told my surgeon that I am Jehovah's Witness and I won't accept a blood transfusion." Which statement by the nurse would be most appropriate?

Correct Answer is B

Explanation

A nurse is educating a client on patient-controlled analgesia (PCA) pump. Which statement made by the client is correct?

Correct Answer is A

Explanation

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

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