Question

A surgical client has been in the PACU for the past 3 hours. What are the determining factors for the client to be discharged from the PACU? Select all that apply.

Answer 1

Correct Answers:

Adequate respiratory function
Sufficient oxygen saturation
Stable blood pressure

Rationale :

💁‍♂️Adequate respiratory function is essential before PACU discharge because it ensures the client can maintain their own airway and perform effective gas exchange independently.

💓Sufficient oxygen saturation indicates that tissue perfusion and oxygen delivery are adequate, reducing the risk of hypoxia after discharge.

🩸Stable blood pressure confirms that hemodynamic stability has been achieved and the client can tolerate normal circulation without support.

🛏️Clients are not required to be pain-free or tolerate fluids before discharge from PACU; the priority is ensuring vital stability and safe recovery from anesthesia.

📌Core Message

PACU discharge depends on stable vital signs, adequate oxygenation, and effective respiratory function ensuring safe recovery from anesthesia.

Answer 2

Correct Answers:

Headache

Rationale :

💉Spinal anesthesia can cause cerebrospinal fluid (CSF) leakage, leading to post-dural puncture headache when the client sits or stands prematurely.

🛏️Remaining flat helps reduce CSF pressure gradients, minimizing the likelihood of this debilitating complication.

🧠Headaches related to spinal anesthesia are caused by fluid shifts in the intracranial space due to gravity effects.

📉Clients should avoid early ambulation or head elevation post spinal procedures to prevent intracranial pressure imbalance.

📌Core Message

Lying flat after spinal anesthesia prevents CSF leakage, reducing the risk of a post-dural puncture headache.

Answer 3

Correct Answers:

"Your nurse will use a pain assessment scale to help rate and treat your pain."

Rationale :

📏Using a pain assessment scale helps ensure that pain is evaluated consistently and managed effectively based on patient-reported intensity.

💊This response supports patient-centered care by involving the client in decisions about their pain control strategy.

🧍Clients should feel empowered to express their pain levels and receive treatment based on individualized needs.

📋Pain is a subjective experience, and regular assessment ensures appropriate analgesic administration and monitoring.

📌Core Message

Postoperative pain management is guided by patient-reported scores on a pain scale, promoting individualized care.

Answer 4

Correct Answers:

The client's next of kin

Rationale :

🧠Clients with Alzheimer's disease are often considered legally incompetent to make medical decisions depending on the disease stage.

📜If a client lacks decision-making capacity, the responsibility falls to the next of kin or legal guardian for informed consent.

🧾The process protects the client’s autonomy and safety, ensuring that decisions are made in their best interest.

⚖️Surgeons must still obtain informed consent, but it must come from someone legally authorized if the client is not competent.

📌Core Message

Clients with cognitive impairment must have consent obtained from their legal representative, often the next of kin.

Answer 5

Correct Answers:

Explain the increased risk for venous thromboembolism after surgery.
Provide resources for smoking cessation.
Encourage smoking cessation before surgery.
Notify the surgeon that the client is a cigarette smoker.

Rationale :

🚬Smoking increases the risk of postoperative complications, including venous thromboembolism (VTE) and poor wound healing.

📚Providing resources for smoking cessation supports client education and health promotion.

💡Encouraging cessation before surgery enhances pulmonary function and reduces anesthetic complications.

📞Notifying the surgeon ensures the team is aware of modifiable risk factors, which may influence pre-op planning.

📌Core Message

Clients who smoke need education, cessation support, and surgical risk planning to prevent complications.

Answer 6

Correct Answers:

The tube provides an airway for ventilation.

Rationale :

💁‍♂️Intubation provides a patent airway that allows for controlled mechanical ventilation during surgery under general anesthesia.

💤Even if surgery is not near the airway, anesthesia depresses respiratory drive, requiring airway support.

🩺It ensures delivery of oxygen and anesthetic gases while protecting the airway from aspiration.

🔄This practice is routine for surgeries requiring deep sedation or muscle relaxation that inhibits spontaneous breathing.

📌Core Message

Intubation is essential to maintain airway patency and support ventilation during general anesthesia.

Answer 7

Correct Answers:

Pneumonia due to reduced respiratory reserve

Rationale :

👵Older adults have a decreased respiratory reserve, making them prone to atelectasis and postoperative pneumonia.

🦠Immobility, reduced cough reflex, and comorbidities increase the risk of infection and hypoventilation.

💁‍♂️Preventing pneumonia involves interventions like incentive spirometry, early ambulation, and deep breathing exercises.

📉Respiratory complications are a leading cause of morbidity in postoperative elderly clients and must be proactively addressed.

📌Core Message

Pneumonia prevention is critical in elderly clients due to reduced lung capacity and increased postoperative risk.

Answer 8

Correct Answers:

Warming reduces the risk of postoperative infection.

Rationale :

🌡️Hypothermia during surgery impairs immune function, increasing the risk of surgical site infections.

🛏️Warm blankets help maintain normothermia, which improves tissue perfusion and healing.

🦠Maintaining body temperature supports white blood cell activity, crucial for infection prevention.

🏥Normothermia is a part of evidence-based perioperative care protocols to improve surgical outcomes.

📌Core Message

Maintaining warmth helps prevent postoperative infection by promoting immune system function.

Answer 9

Correct Answers:

The client should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs.

Rationale :

💨This breathing pattern helps promote lung expansion and mobilize secretions, reducing atelectasis risk.

💁‍♂️Deep breathing increases alveolar inflation, improving oxygenation and preventing hypoventilation.

👉Exhaling through the mouth and deep coughing clears the lower airways of accumulated mucus.

🗣️Teaching clients this technique preoperatively prepares them to effectively manage pulmonary hygiene after surgery.

📌Core Message

Proper breathing and coughing techniques promote airway clearance and prevent postoperative complications.

Answer 10

Correct Answers:

Offer the client a bedpan or urinal.

Rationale :

💊Benzodiazepines can impair coordination and mental status, increasing fall risk if the client tries to ambulate.

🛏️Offering a bedpan or urinal is the safest choice to meet needs while avoiding injury.

🚷Clients given pre-op sedatives should not be allowed to walk due to potential for dizziness and unsteadiness.

⚠️This action demonstrates fall prevention and supports safe preoperative care planning.

📌Core Message

After receiving benzodiazepines, clients must avoid ambulation and be offered a safe voiding alternative.

1 :
A surgical client has been in the PACU for the past 3 hours. What are the determining factors for the client to be discharged from the PACU? Select all that apply.

3 :
The nurse in preadmission testing is educating a client about a scheduled surgery. Which response should the nurse give when the client asks about pain management following surgery?

4 :
The nurse is checking the informed consent for an older adult client who requires surgery and who has recently been diagnosed with Alzheimer's disease. When obtaining informed consent, who is legally responsible for signing?

5 :
The nurse in preadmission testing learns that a client scheduled for a total hip replacement in three weeks smokes one pack of cigarettes per day. Which action(s) should the nurse take? Select all that apply.

6 :
A client waiting in the presurgical holding area asks the nurse, "Why exactly do they have to put a breathing tube into me? My surgery is on my knee." What is the best rationale for intubation during a surgical procedure that the nurse should describe?

7 :
A 90-year-old client is scheduled to undergo surgery. Prevention of which potential complication should the nurse prioritize when planning this client's postoperative care?

8 :
The nurse in the preoperative area places a warmed blanket on a client. Which reason does the nurse give the client for this action?

9 :
In anticipation of a client’s scheduled surgery, the nurse is teaching the client to perform deep breathing and coughing to use postoperatively. What action should the nurse teach the client?

10 :
During the care of a preoperative client, the nurse has given the client a preoperative benzodiazepine. The client is now requesting to void. What action should the nurse take?

1 : A surgical client has been in the PACU for the past 3 hours. What are the determining factors for the client to be discharged from the PACU? Select all that apply.

3 : The nurse in preadmission testing is educating a client about a scheduled surgery. Which response should the nurse give when the client asks about pain management following surgery?

4 : The nurse is checking the informed consent for an older adult client who requires surgery and who has recently been diagnosed with Alzheimer's disease. When obtaining informed consent, who is legally responsible for signing?

5 : The nurse in preadmission testing learns that a client scheduled for a total hip replacement in three weeks smokes one pack of cigarettes per day. Which action(s) should the nurse take? Select all that apply.

6 : A client waiting in the presurgical holding area asks the nurse, "Why exactly do they have to put a breathing tube into me? My surgery is on my knee." What is the best rationale for intubation during a surgical procedure that the nurse should describe?

7 : A 90-year-old client is scheduled to undergo surgery. Prevention of which potential complication should the nurse prioritize when planning this client's postoperative care?

8 : The nurse in the preoperative area places a warmed blanket on a client. Which reason does the nurse give the client for this action?

9 : In anticipation of a client’s scheduled surgery, the nurse is teaching the client to perform deep breathing and coughing to use postoperatively. What action should the nurse teach the client?

10 : During the care of a preoperative client, the nurse has given the client a preoperative benzodiazepine. The client is now requesting to void. What action should the nurse take?

1 :
A surgical client has been in the PACU for the past 3 hours. What are the determining factors for the client to be discharged from the PACU? Select all that apply.

3 :
The nurse in preadmission testing is educating a client about a scheduled surgery. Which response should the nurse give when the client asks about pain management following surgery?

4 :
The nurse is checking the informed consent for an older adult client who requires surgery and who has recently been diagnosed with Alzheimer's disease. When obtaining informed consent, who is legally responsible for signing?

5 :
The nurse in preadmission testing learns that a client scheduled for a total hip replacement in three weeks smokes one pack of cigarettes per day. Which action(s) should the nurse take? Select all that apply.

6 :
A client waiting in the presurgical holding area asks the nurse, "Why exactly do they have to put a breathing tube into me? My surgery is on my knee." What is the best rationale for intubation during a surgical procedure that the nurse should describe?

7 :
A 90-year-old client is scheduled to undergo surgery. Prevention of which potential complication should the nurse prioritize when planning this client's postoperative care?

8 :
The nurse in the preoperative area places a warmed blanket on a client. Which reason does the nurse give the client for this action?

9 :
In anticipation of a client’s scheduled surgery, the nurse is teaching the client to perform deep breathing and coughing to use postoperatively. What action should the nurse teach the client?

10 :
During the care of a preoperative client, the nurse has given the client a preoperative benzodiazepine. The client is now requesting to void. What action should the nurse take?