Safety Needs Flashcards

A nurse in the PACU is caring for a post-operative patient who is drowsy but responsive. The nurse notices the side rails are down, and the patient begins to move. What is the nurse’s immediate action?

Answer: Raise the side rails and ensure the call light is within reach.

Patient safety is the paramount concern, especially for a drowsy but responsive post-operative patient who is moving. Raising the side rails immediately prevents falls from the bed, while ensuring the call light is accessible empowers the patient to request assistance, reducing the need for them to attempt to get out of bed independently. This proactive approach minimizes fall risk and promotes a safe environment.

While caring for a patient receiving IV opioid pain medication, the nurse observes that the patient’s respiratory rate has dropped to 8 breaths per minute. What is the nurse’s priority intervention?

Answer: Administer naloxone (Narcan) as prescribed.

A respiratory rate of 8 breaths per minute in a patient receiving IV opioid pain medication is a clear sign of opioid-induced respiratory depression, which is a life-threatening emergency. Naloxone is an opioid antagonist that rapidly reverses the effects of opioids, including respiratory depression. Administering it as prescribed is the immediate and most effective intervention to restore adequate ventilation.

The nurse prepares to transport a patient from the PACU to the surgical floor. Which of the following is most important to verify before transport?

Answer: The patient’s airway is stable, and vital signs are within normal limits.

Ensuring a stable airway and vital signs within normal limits is the most critical criterion for safe patient transport from the PACU. These parameters reflect the patient's physiological stability and readiness to be moved to a less intensively monitored environment. While other factors like pain control or voiding are important, they are secondary to maintaining basic life support functions during transfer.

A patient recovering from surgery becomes restless and tries to remove their IV catheter. What is the nurse’s best action?

Answer: Reorient the patient and assess for pain, hypoxia, or delirium.

Restlessness and attempts to remove medical devices in a post-operative patient can stem from various causes, including pain, hypoxia, or delirium. The best action is to first attempt verbal reorientation and then systematically assess for these underlying physiological causes. Addressing the root cause is more therapeutic and safer than immediate restraint or sedation, which can mask critical symptoms.

During a post-operative assessment, the nurse notices a small pool of blood forming under the patient’s surgical dressing. What is the nurse’s immediate action?

Answer: Reinforce the dressing with additional sterile gauze and notify the surgeon.

If a surgical dressing shows signs of bleeding, the immediate action is to reinforce the existing dressing with additional sterile gauze to apply pressure and contain the bleeding. Removing the dressing could disrupt clot formation and increase bleeding. After reinforcing, notifying the surgeon is crucial for further assessment and management, as they may need to intervene if bleeding continues.