A postanesthesia care unit (PACU) nurse is assessing a ...

[schs14]

A postanesthesia care unit (PACU) nurse is assessing a postoperative client with a nasogastric (NG) tube. What laboratory values would warrant intervention by the nurse? (Select all that apply.)
 
  a. Blood glucose: 120 mg/dL
  b. Hemoglobin: 7.8 mg/dL
  c. pH: 7.68
  d. Potassium: 2.9 mEq/L
  e. Sodium: 142 mEq/L

Question 2

A nurse orienting to the postoperative area learns which principles about the postoperative period? (Select all that apply.)
 
  a. All phases require the client to be in the hospital.
  b. Phase I care may last for several days in some clients.
  c. Phase I requires intensive care unit monitoring.
  d. Phase II ends when the client is stable and awake.
  e. Vital signs may be taken only once a day in phase III.

[Pariscourtney]

Answer to Question 1

ANS: B, C, D
Fluid and electrolyte balance are assessed carefully in the postoperative client because many imbalances can occur. The low hemoglobin may be from blood loss in surgery. The higher pH level indicates alkalosis, possibly from losses through the NG tube. The potassium is very low. The blood glucose is within normal limits for a postsurgical client who has been fasting. The sodium level is normal.

Answer to Question 2

ANS: B, D, E
There are three phases of postoperative care. Phase I is the most intense, with clients coming right from surgery until they are completely awake and hemodynamically stable. This may take hours or days and can occur in the intensive care unit or the postoperative care unit. Phase II ends when the client is at a presurgical level of consciousness and baseline oxygen saturation, and vital signs are stable. Phase III involves the extended care environment and may continue at home or in an extended care facility if needed.