Clinical Procedures and Protocols Flashcards

A patient is admitted to the PACU following a thoracotomy with a chest tube to water-seal drainage. The nurse observes continuous bubbling in the water-seal chamber. This finding indicates:

Answer: An air leak that requires immediate notification of the surgeon

Continuous bubbling in the water-seal chamber indicates an ongoing air leak from the pleural space or at the chest tube insertion site, which requires surgical notification.

Which pharmacologic agent is the drug of choice for treating bronchospasm in the PACU?

Answer: Albuterol via nebulizer or MDI

Albuterol, a short-acting beta-2 agonist delivered via nebulizer or MDI, is the first-line pharmacologic treatment for bronchospasm due to its rapid onset and bronchodilatory effect.

A PACU patient reports a pain score of 8/10 and has received maximum opioid doses per protocol. Which non-pharmacologic adjunct is MOST appropriate at this time?

Answer: Distraction and deep breathing exercises

Non-pharmacologic techniques such as distraction and guided deep breathing can reduce pain perception and anxiety when pharmacologic limits have been reached.

During PACU assessment, a patient demonstrates confusion, hypertension, tachycardia, and diaphoresis after receiving meperidine. Which condition should the nurse suspect?

Answer: Serotonin syndrome

Meperidine can cause serotonin syndrome when combined with serotonergic medications; presenting symptoms include altered mental status, autonomic instability, and neuromuscular abnormalities.

When assessing an epidural catheter in the PACU, the nurse notes the patient has no sensation or motor function below T4. The nurse's priority intervention is:

Answer: Stop the epidural infusion and notify the anesthesia provider

A high spinal or epidural block above T4 can compromise respiratory function and hemodynamic stability, requiring immediate cessation of the infusion and anesthesia notification.

A post-thyroidectomy patient in the PACU develops inspiratory stridor, dysphagia, and neck swelling. The nurse's immediate priority is:

Answer: Prepare for emergency airway management and alert the surgeon

Post-thyroidectomy stridor with neck swelling suggests hematoma-induced airway compromise, which is a surgical emergency requiring immediate airway preparation and surgeon notification.

Which criterion must be met before a patient can be safely discharged from a Phase I PACU to Phase II or an inpatient unit?

Answer: Patient must meet facility-approved discharge scoring criteria such as a Modified Aldrete Score of ≥9

Discharge from Phase I PACU requires meeting a validated scoring threshold (e.g., Modified Aldrete ≥9) that ensures adequate recovery of vital functions per ASPAN standards.