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:

🔷 Airway patency and an effective respiratory rate/depth are core criteria for PACU discharge because they determine the client’s ability to ventilate without assistance.

🔷 Clients must demonstrate spontaneous, unlabored breathing with no signs of obstruction or accessory-muscle use.

🔷 Adequate ventilation lowers the risk of hypoventilation, hypoxemia, and CO₂ retention once monitoring decreases on the ward.

🔷 PACU scoring tools (e.g., Aldrete) weight respiration heavily when determining readiness.

🔷 Ensuring respiratory adequacy supports safe transition from the highly monitored PACU to a lower-acuity setting.

Sufficient oxygen saturation:

🔷 A stable SpO₂ at or near baseline (commonly ≥ 92–94% on room air or with minimal supplemental O₂) confirms effective gas exchange.

🔷 Adequate saturation verifies that oxygen delivery to tissues will remain sufficient after transfer.

🔷 It reduces the chance of occult hypoxemia as sedatives/anesthetics wear off.

🔷 SpO₂ is an objective metric that complements respiratory assessment and validates discharge readiness.

🔷 Documented, stable SpO₂ is a standard discharge parameter in PACU pathways.

Stable blood pressure:

🔷Hemodynamic stability (BP and HR near preop baseline) indicates effective circulatory compensation after anesthesia and fluid shifts.

🔷Stable BP lowers risk of syncope, organ hypoperfusion, and bleeding after transfer.

🔷It suggests adequate volume status and recovery from anesthetic-related vasodilation.

🔷PACU discharge criteria typically require BP within ~20% of baseline without escalating support.

🔷Together with mentation and respiration, stable vitals confirm safe progression of care.

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Answer 2

Correct Answers:

Headache

Rationale :

🔶After spinal anesthesia, CSF can leak through the dural puncture site, predisposing to a post-dural puncture headache (PDPH).

🔶Lying flat decreases hydrostatic pressure at the puncture site, helping the dural hole seal and reducing CSF loss.

🔶Preventing CSF leakage reduces traction on intracranial pain-sensitive structures, which lowers headache incidence/severity.

🔶Early adherence to the supine order complements hydration and caffeine as noninvasive strategies to limit PDPH.

🔶This positioning precaution supports a safer, more comfortable recovery from neuraxial anesthesia.

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Answer 3

Correct Answers:

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

Rationale :

💠 Use of a standardized pain scale (e.g., 0–10, faces scale) ensures objective, consistent assessment and guides timely analgesia.

💠 Early, scheduled, and multimodal pain strategies (non-opioids, regional techniques, adjuncts) improve comfort and reduce opioid needs.

💠 Encouraging the client to report pain early prevents escalation and promotes mobility, deep breathing, and recovery.

💠 Pain is the “fifth vital sign” and requires routine reassessment to evaluate response and side effects.

💠 Clear communication about the pain plan builds trust and realistic expectations, improving postoperative outcomes.

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Answer 4

Correct Answers:

The client

Rationale :

💎 Informed consent must be signed by the client when they possess decision-making capacity (understands, appreciates, reasons, and can express a choice).

💎 A diagnosis of Alzheimer’s does not automatically negate capacity; capacity is decision-specific and can be intact early in disease.

💎 The nurse should verify orientation and that the client comprehends the procedure, risks, benefits, and alternatives.

💎 If capacity is lacking, consent is obtained from the legally authorized representative designated by law or advance directive (not assumed by relationship alone).

💎 When capacity is present, the client’s signature is the legally valid authorization for surgery.

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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 :

Explain increased VTE risk:

◈ Total hip replacement carries a high baseline risk for venous thromboembolism (VTE); smoking adds prothrombotic and endothelial-injury risks.

◈ Educating on VTE risk reinforces the importance of early ambulation, pharmacologic prophylaxis, and SCDs postoperatively.

◈ Understanding risk improves adherence to mobility goals and anticoagulation protocols if prescribed.

◈ This teaching ties smoking to perioperative complications, motivating behavior change.

◈ Clear risk discussion supports informed participation in the plan of care.

Provide cessation resources:

◈ Offering smoking-cessation resources (NRT, counseling, quit lines) is evidence-based and improves quit rates.

◈ Even a few smoke-free weeks preop improves pulmonary function and wound healing.

◈ Concrete resources convert advice into an actionable plan.

◈ Documenting resources given ensures continuity across the perioperative team.

◈ Empowering cessation enhances short- and long-term outcomes.

Encourage cessation before surgery:

◈ Preoperative abstinence reduces atelectasis, pneumonia, bronchospasm, and SSI risk and may shorten LOS.

◈ The earlier the quit date, the greater the physiologic recovery (e.g., ciliary function and oxygenation).

◈ Setting a quit date and follow-ups raises success rates.

◈ Positive, nonjudgmental counseling improves engagement.

◈ Cessation aligns with enhanced recovery and safer anesthesia.

Notify the surgeon:

◈ Communicating smoking status to the surgeon/anesthesia team ensures planning for airway, analgesia, and pulmonary risk.

◈ The provider may initiate preop optimization (e.g., NRT) and adjust VTE prophylaxis or respiratory strategies.

◈ Team awareness promotes targeted postop monitoring for respiratory compromise.

◈ This handoff meets safety and documentation standards in preadmission testing.

◈ Early notification supports a coordinated perioperative plan.

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Answer 6

Correct Answers:

The tube provides an airway for ventilation.

Rationale :

✴ During many surgeries, general anesthesia depresses protective reflexes and respiratory drive, requiring a secure airway.

✴ Endotracheal intubation maintains a patent airway and enables controlled ventilation and oxygenation.

✴ It also allows delivery of inhaled anesthetics and precise control of ETCO₂ and tidal volumes.

✴ A secured airway protects against aspiration when combined with appropriate techniques.

✴ Overall, intubation ensures safe, reliable gas exchange throughout the procedure.

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Answer 7

Correct Answers:

Pneumonia due to reduced respiratory reserve

Rationale :

🟣 Older adults have decreased chest wall compliance, weaker cough, and reduced ciliary function, increasing postoperative pneumonia risk.

🟣 Anesthesia, pain, and immobility promote atelectasis, which predisposes to infection.

🟣 Prevention focuses on incentive spirometry, deep breathing/coughing, early ambulation, and adequate analgesia.

🟣 Head-of-bed elevation and oral hygiene further lower pulmonary complications.

🟣 Prioritizing pulmonary prevention reduces morbidity, LOS, and readmissions in geriatric surgical clients.

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Answer 8

Correct Answers:

Warming reduces the risk of postoperative infection.

Rationale :

🔵 Perioperative normothermia preserves tissue perfusion and oxygen tension, key defenses against surgical-site infection (SSI).

🔵 Hypothermia causes vasoconstriction and impairs neutrophil function and collagen deposition, hindering wound healing.

🔵 Active warming (forced-air/warmed blankets) reduces SSI rates and improves patient comfort.

🔵 Maintaining temperature also minimizes shivering, coagulopathy, and cardiac stress.

🔵 Early warming in preop/PACU embeds a bundle approach to SSI prevention.

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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 :

🟢Teaching a structured deep-breathing and cough sequence promotes lung expansion and secretion clearance after anesthesia.

🟢A slow deep inspiration, brief hold, and controlled exhalation prime the lungs for an effective, diaphragmatic cough.

🟢The follow-up short breath sets up a strong cough to move secretions from the lower airways.

🟢Performing this routine regularly (with incision splinting if needed) prevents atelectasis and pneumonia.

🟢Consistency with this technique improves oxygenation, comfort, and recovery.

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Answer 10

Correct Answers:

Offer the client a bedpan or urinal.

Rationale :

🟡Benzodiazepines impair balance, cognition, and reaction time, increasing fall risk minutes after administration.

🟡Providing a bedpan/urinal meets physiologic needs while preserving safety and dignity.

🟡Avoiding ambulation after sedative premedication adheres to perioperative safety protocols.

🟡Documenting intake/output without unnecessary transfers supports accurate perioperative records.

🟡This approach balances comfort, safety, and efficiency before OR transfer.

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Adult Nursing II-Exam 1

No.

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?

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Adult Nursing II-Exam 1

No.

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?