Author Question: In the postanesthesia care unit (PACU), a patient's vital signs are blood pressure 116/72, pulse 74, ... (Read 36 times)

schs14 · **on:** Jun 25, 2018

In the postanesthesia care unit (PACU), a patient's vital signs are blood pressure 116/72, pulse 74, respirations 12, and SpO2 91. The patient is sleepy but awakens easily. Which action should the nurse take first?

a. Place the patient in a side-lying position.
b. Encourage the patient to take deep breaths.
c. Prepare to transfer the patient to a clinical unit.
d. Increase the rate of the postoperative IV fluids.

Question 2

An experienced nurse orients a new nurse to the postanesthesia care unit (PACU). Which action by the new nurse, if observed by the experienced nurse, indicates that the orientation was successful?

a. The new nurse assists a nauseated patient to a supine position.
b. The new nurse positions an unconscious patient supine with the head elevated.
c. The new nurse turns an unconscious patient to the side upon arrival in the PACU.
d. The new nurse places a patient in the Trendelenburg position when the blood pressure drops.

6ana001 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: B
The patient's borderline SpO2 and sleepiness indicate hypoventilation. The nurse should stimulate the patient and remind the patient to take deep breaths. Placing the patient in a lateral position is needed when the patient first arrives in the PACU and is unconscious. The stable blood pressure and pulse indicate that no changes in fluid intake are required. The patient is not fully awake and has a low SpO2, indicating that transfer from the PACU to a clinical unit is not appropriate.

Answer to Question 2

ANS: C
The patient should initially be positioned in the lateral recovery position to keep the airway open and avoid aspiration. The Trendelenburg position is avoided because it increases the work of breathing. The patient is placed supine with the head elevated after regaining consciousness.