Clinical Procedures and Protocols Flashcards

A PACU patient develops laryngospasm after extubation. Which intervention should the nurse perform FIRST?

Answer: Apply positive pressure ventilation with 100% oxygen

Positive pressure ventilation with 100% oxygen is the first-line intervention for laryngospasm, as it can break mild-to-moderate spasm before pharmacologic intervention is needed.

Which assessment finding in the PACU indicates the patient has achieved adequate reversal of neuromuscular blockade?

Answer: Train-of-four ratio ≥0.9

A train-of-four ratio ≥0.9 indicates adequate neuromuscular recovery and is the standard criterion for confirming reversal of neuromuscular blockade.

A patient in the PACU has a blood pressure of 80/50 mmHg with a heart rate of 120 bpm after abdominal surgery. Which intervention takes priority?

Answer: Administer an IV fluid bolus of 500 mL normal saline

Hypovolemic hypotension in the PACU is first treated with IV fluid resuscitation to restore intravascular volume before vasopressors are considered.

When performing a Modified Aldrete Score assessment, which criterion evaluates the patient's ability to breathe deeply and cough freely?

Answer: Respiration

The Respiration criterion of the Modified Aldrete Score assesses the patient's ability to breathe deeply and cough freely, scored 0–2.

A PACU nurse notices a patient's wound dressing is saturated with bright red blood 30 minutes post-operatively. What is the nurse's priority action?

Answer: Apply direct pressure and notify the surgeon immediately

Applying direct pressure to control bleeding and immediately notifying the surgeon is the priority to prevent further blood loss and facilitate prompt surgical intervention if needed.

Which position is most appropriate for a PACU patient recovering from posterior fossa craniotomy?

Answer: Head of bed elevated 30 degrees with neck in neutral alignment

Elevating the head of bed 30 degrees with neutral neck alignment reduces intracranial pressure and promotes venous drainage without compromising cerebral perfusion.

A patient arrives in the PACU with suspected malignant hyperthermia. After calling for help and administering dantrolene, what cooling measure is most effective?

Answer: Administer cold IV saline and apply ice to large vessel areas

Active external cooling with ice packs to major vascular areas combined with cold IV saline infusion is the most effective emergent cooling strategy for malignant hyperthermia.