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2024 POSTOPERATIVE NURSING MANAGEMENT, THE PACU EXAM 2 WITH CORRECT ANSWERS
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2024 POSTOPERATIVE NURSING MANAGEMENT, THE PACU EXAM 2 WITH CORRECT ANSWERS
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2024 POSTOPERATIVE NURSINGMANAGEMENT, THE PACU EXAM 2
WITH CORRECT ANSWERS
What are the 3 phases of recovery that occur in the PACU? - CORRECT-
ANSWERS1)Immediate recovery phase: intensive nursing care provided. 2)
less intensive care: patient prepared for self care in PACU or transfer to an
inpatient unit or outpatient unit. 3) exntended care/observation unit: patient
prepared for discharge.
what is hypothermia? - CORRECT-ANSWERScore temperature less than 96.8
occurs when heat loss exceeds production, cold OR, exposed body organs,
prolonged, anesthesia, long surgery.
what are interventions for hypothermia? - CORRECT-ANSWERSpassive re-
warming is shivering. active rewarming-blankets, heated aerosols, radiant
warmers, forced air warmers, or heated water ex bair huggers.
What is nursing management for hypothermia? - CORRECT-ANSWERSmonitor
body temperature at 15 minute intervals when using any external warming
device. skin care to prevent injuries. oxygen therapy for increasing demand.
What criteria must be met for discharge from the PACU? - CORRECT-
ANSWERSO2 saturation must be maintained >92% on RA if achieve the
above, given 2pts in each area a total of 10 points. scored on admission & @
15min intervals. requires 7-8 points for discharge from PACU,
anesthesiologist must approve all PACU discharges.
What criteria must be met for ambulatory discharge criteria? - CORRECT-
ANSWERSAll PACU discharge criteria met, no IV narcotics last 30 minutes,
minimal n/v, voided if appropriate, able to ambulate, adult driver available,
discharge instructions given/understood.
What happens when the patient in moved from the PACU to the clinical unit?
- CORRECT-ANSWERSPACU nurse gives report to receiving nurse. vital signs
obtained, compared to report, perform initial admitting assessment.
What does the nurse on the clinical unit assess for? - CORRECT-
ANSWERSatelectasis/hypoxemia/pneumonia/bleeding/hematoma. DVT,
, pulmonary embolism, infection, paralytic ileus, urinary retention, wound
dehisence/evisceration.
why is the respiratory system continually assessed? - CORRECT-
ANSWERSdue to depressive effects of opioids, pain, decreased mobility, s/s
breathe sounds diminished, crackles at bases, cough.
what are interventions when respiratory depression is occuring? - CORRECT-
ANSWERSincentive spirometer q 10 mins while awake, turns, cough & deep
breath ever 2 hrs.
What cardiovascular problems can occur in the clinical setting after the
PACU? - CORRECT-ANSWERSfluid retention-during first 2-5 days postop due
to stress response(third spacing). Fluid overload-IVF are administered too
rapidly, chronic disease exists, or when patient is older. fluid deficit-vomiting,
bleeding, wound drainage. hypokalemia-urinary/GI tract losses, syncope-
usually from postural hypotension.
What are interventions for cardiovascular problems? - CORRECT-
ANSWERSaccurate I & Os, monitor laboratory findings, assessment of
infusion rate of fluid replacement, adequate mouth care/
what are DVTs? - CORRECT-ANSWERSdeep vein thrombosis. stress response
leads to increas in clotting. develops due to prolonged bed rest, body
position and pressure leading to venous stasis. s/s: pain/cramp of entire
leg/calf, swelling of calf, fever, chills. risk for pulmonary embolus,
heparin/enoxaparin sodium, SCDs or TED hose, ankle/leg exercises,
ambulation, fluids: avoid dehydration.
What is a pulmonary embolism? - CORRECT-ANSWERSclot dislodged from
peripheral venous system into pulmonary arterial system. S/S: dyspnea,
sudden chest pain, tachycardia, low BP, tachypnea, low O2 saturation,
cyanosis. Treatment: oxygen, semi-fowlers position, fluids, monitor vital
signs often, ECG, ABG, Heparin, cardiopulmonary support.
What are potential alterations/management in urinary function? - CORRECT-
ANSWERSlow urinary output may be expected in the first 24 hrs, regardless
of intake, minimum 30ml/hr. loss of tone from anesthetic or opioids seen 6-8
hrs postoperative can result in urinary retention. expected to void within 8
hrs after surgery.
what are interventions for urinary complications? - CORRECT-
ANSWERSassess for bladder distention, position upright. straight catheter.
bethanechol (urecholine) usually 10mg po q 6hrs x 3 doses or until client has
voided after catheter removed.
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