Exam 1 - PACU (Nursing 2)|well answered questions, Exams of Nursing

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Exam 1 - PACU (Nursing 2)

PACU stands for: - answer; post-anesthesia care unit The primary purpose of the PACU is: - answer; ongoing critical evaluation and stabilization of pt. Upon admission, the pt must be: - answer; placed on/with EKG, pulse ox, BP cuff, and oxygen When a pt arrives in PACU, the ___ gives report. - answer; CRNA/Anesth. Phase 1: - answer; Intense monitoring, preparing pt for d/c or inpatient unit Phase 2: - answer; Preparing pt for Phase III, home, or rehab facility Phase 3: - answer; Preparing pt for self care, observation, rehab Fast tracking: - answer; Pt admitted to PACU after local or regional anesthesia Intraoperative management while giving admission report: - answer; what anesthesia was used, meds given, EBL, fluid replacement totals, urine output Intraoperative course while giving admission report: - answer; unexpected anesthetic events/reactions, VS, monitoring trends, lab results PACU assessment priority: - answer; Adequacy of airway (rate, rhythm, accessory muscles, breath sounds, O2 sat) Pts at higher risk in PACU: - answer; those that received general, elderly, smokers/lung disease, obese, pts that went under thoracic/airway/abd surgery

Obese pts are at a higher risk in PACU due to: - answer; adipose tissue absorbing anesthesia and slowly releasing over time, they're harder to wake Reasons for airway obstruction: - answer; blockage (usually tongue), supine position, extremely sleepiness, laryngospasm (throat close), retained secretions, laryngeal edema (from neck surgery) The most common cause of postop hypoxemia: - answer; atelectasis Atelectasis: - answer; complete or partial lung collapse, may result from retained secretions Assessing cardio status: - answer; EKG monitoring, VS q15m, peripheral vascular assessment Assessing neurology: - answer; LOC, orientation, sensory/motor status, pupil equality/size The main info that's helpful in assessing a patient is knowing their: - answer; baseline vitals/labs A pt in PACU should be voiding at least: - answer; 30 mL/hr When a pt is waking, their first sense to return is: - answer; hearing You should orient the pt waking up by: - answer; explaining the surgery is over, location of pt, family/friend is notified, RN's name Discharge criteria: - answer; awake, VS stable, no excessive bleeding/draining, no resp depression, pulse ox < 90%, report given S/S of pulmonary embolism: - answer; SOA, rapid pulse, cold sweat, anxious, sudden panic Homan's sign: - answer; when a pt flexes their feet and it causes deep pain in their leg

DVT's are a huge risk because: - answer; the clot can travel to the lungs, heart, or brain Notify HCP if pt experiences: - answer; Systolic <90 or >160, pulse <90 or >120, BP gradually increases, irregular cardiac rhythm Urinary complications: - answer; Retention, infection, altered drug excretion S/S paralytic ileus: - answer; abd cramping that comes and goes, loss of appetite, constipation, vomiting, inability to pass gas or feces, abd distention Postop GI complications: - answer; NV, abd distention, constipation Dehiscence: - answer; Surgical wound separation within 1 week postop Evisceration: - answer; Protrusion of tissue through dehiscence Cause of dehiscence: - answer; obese, poor skin integrity Effective ___ will promote effective healing. - answer; pain management Benefits of early ambulation: - answer; increases muscle tone, improves GI/urinary tract fx, stimulates circulation, assist in respiratory fx When a pt is admitted to the PACU, what are the priority interventions the RN performs? A. assess surgical site, noting presence and character of drainage B. assess the amount of urine output and the presence of the bladder distention C. assess for airway patency and quality of respirations, and obtain VS D. review results of intraoperative lab values and medications received - answer; Airway

After admission to the PACU, which assessment requires the most immediate attention? A. O2 85% B. Resp rate 13/min C. Temp 100.4 F D. BP 90/60 - answer; O A 70 kg postop pt has an average urine output of 25 mL/hr during the first 8 hrs. The priority should be: A. perform a straight cath to measure the amount of urine in bladder B. notify the HCP and anticipate blood work to eval renal fx C. continue to monitor the pt because this is a normal finding in this period D. eval the pt's fluid volume status since surgery and obtain a bladder u/s - answer; Eval the fluid volume and bladder u/s D/c criteria for the Phase II pt includes (select all that apply): A. no N/V B. ability to drive self home C. no resp depression D. written d/c instructions understood E. opioid med given 45 min ago - answer; no resp depression, written d/c understood, opioid med given