On admission of a patient to the postanesthesia care unit (PACU), ...

[pragya sharda]

On admission of a patient to the postanesthesia care unit (PACU), the blood pressure (BP) is 122/72. Thirty minutes after admission, the BP falls to 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate?
 
  a. Increase the IV fluid rate.
  b. Continue to take vital signs every 15 minutes.
  c. Administer oxygen therapy at 100 per mask.
  d. Notify the anesthesia care provider (ACP) immediately.

Question 2

Which actions will the nurse include in the surgical time-out procedure before surgery (select all that apply)?
 
  a. Check for placement of IV lines.
  b. Have the surgeon identify the patient.
  c. Have the patient state name and date of birth.
  d. Verify the patient identification band number.
  e. Ask the patient to state the surgical procedure.
  f. Confirm the hospital chart identification number.

[ong527]

Answer to Question 1

ANS: B
A slight drop in postoperative BP with a normal pulse and warm, dry skin indicates normal response to the residual effects of anesthesia and requires only ongoing monitoring. Hypotension with tachycardia and/or cool, clammy skin would suggest hypovolemic or hemorrhagic shock and the need for notification of the ACP, increased fluids, and high-concentration oxygen administration.

Answer to Question 2

ANS: C, D, E, F
These actions are included in surgical time out. IV line placement and identification of the patient by the surgeon are not included in the surgical time-out procedure.

[pragya sharda]

TYSM

[bulacsom]

Excellent