Which nursing action is completed during phase III of post anesthesia care?
Discharge teaching
Recovery from anesthesia
Urinary catheterization if no voiding
Vital signs every 15 to 30 minutes
The Correct Answer is A
A. Discharge teaching: Phase III of post-anesthesia care focuses on preparing the patient for discharge, including teaching about post-operative care, medication instructions, and follow-up care.
B. Recovery from anesthesia: This occurs in Phase I, where patients are closely monitored as they emerge from anesthesia and regain protective reflexes.
C. Urinary catheterization if no voiding: This may be considered in Phase II, especially if urinary retention is present, but is not a defining activity of Phase III.
D. Vital signs every 15 to 30 minutes: Frequent monitoring of vital signs is a key part of Phase I, when patients are at the highest risk for complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Chest physiotherapy (CPT) every 4 hours while awake. CPT is used to mobilize secretions but may be too aggressive for a patient with infiltrates and respiratory distress, as it can increase fatigue and worsen respiratory status.
B. Oxygen therapy via nasal cannula at 3 to 4 L/min. Low-flow oxygen therapy is often used in COPD to prevent hypoxemia while avoiding CO₂ retention.
C. Add humidification to the oxygen source. Humidified oxygen helps prevent airway dryness and improves secretion clearance, which is beneficial for COPD patients.
D. Raise the head of the patient's bed. Elevating the head of the bed promotes lung expansion and improves oxygenation, making this an appropriate intervention.
Correct Answer is D
Explanation
A. Assessment, diagnosis, intervention, evaluation, discharge, documentation. Discharge and documentation are important but are not part of the core nursing process.
B. Assessment, planning, intervention, evaluation, discharge, follow-up. Follow-up is not a standard step in the nursing process.
C. Assessment, diagnosis, planning, interventions, evaluation, education. Education is important but is not one of the six standard nursing process steps.
D. (Re)Assessment, diagnosis, outcomes, planning, implementation, evaluation. This accurately outlines the nursing process, which involves reassessing the patient, diagnosing, setting expected outcomes, planning care, implementing interventions, and evaluating effectiveness.
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