Clinical Procedures and Protocols Flashcards

A patient in the PACU complains of severe headache, photophobia, and neck stiffness after spinal anesthesia. The nurse should first suspect:

Answer: Post-dural puncture headache

Post-dural puncture headache (PDPH) is the most common cause of these symptoms after spinal anesthesia due to CSF leakage through the dural puncture site.

A PACU patient who received spinal anesthesia has a block level at T6 and develops bradycardia (HR 42 bpm) and hypotension. The nurse anticipates administering:

Answer: Atropine and IV fluid bolus

High spinal block can cause sympathectomy leading to bradycardia and hypotension, treated with atropine for the heart rate and IV fluids or vasopressors for blood pressure.

A patient recovering from ambulatory surgery asks to be discharged. The nurse notes the patient cannot stand without dizziness. Using the PADSS criteria, this patient should receive a score of:

Answer: 1 for the ambulation criterion

The Post-Anesthetic Discharge Scoring System (PADSS) scores ambulation as 1 when the patient has dizziness/giddiness but is able to ambulate with assistance.

A Phase II PACU patient is being prepared for home discharge after outpatient laparoscopic surgery. Which discharge instruction is MOST critical for patient safety?

Answer: Do not drive or operate machinery for 24 hours after anesthesia

Residual anesthetic and sedative effects impair psychomotor function for up to 24 hours; driving prohibition is a mandatory patient safety instruction after general or sedation anesthesia.

In the PACU, a patient receiving a heparin infusion after vascular surgery develops oozing from IV sites and hematuria. The nurse suspects heparin-induced coagulopathy and expects which laboratory finding?

Answer: Supratherapeutic aPTT greater than 120 seconds

Bleeding with heparin therapy most commonly results from a supratherapeutic aPTT; values >120 seconds significantly increase hemorrhagic risk and warrant dose adjustment or reversal with protamine.

A PACU nurse assesses a patient post-cardiac surgery and notes the mediastinal chest tube has suddenly stopped draining after outputting 300 mL/hr for 2 hours. The nurse should first:

Answer: Assess for tube kinking and signs of cardiac tamponade

Abrupt cessation of mediastinal drainage after high output may indicate clot obstruction and impending tamponade; immediate assessment for tube kinking and tamponade signs is essential.

Which intervention is the gold standard for confirming correct endotracheal tube placement in a PACU patient requiring reintubation?

Answer: Continuous waveform capnography with CO2 detection

Continuous waveform capnography is the gold standard for confirming endotracheal tube placement because it provides real-time CO2 waveform data that unequivocally confirms tracheal intubation.