Patient Assessment and Evaluation Flashcards

A post-anesthesia patient has a respiratory rate of 8 breaths/min and SpO2 of 88% on room air. After applying 6L/min oxygen via face mask, SpO2 rises to 94%. What is the most likely cause of initial hypoxemia?

Answer: Hypoventilation from residual opioid effect

A slow respiratory rate with improvement on supplemental oxygen suggests opioid-induced hypoventilation, the most common cause of post-anesthesia hypoxemia.

When assessing a post-anesthesia patient using the Aldrete scoring system, which parameter evaluates the patient's ability to follow commands?

Answer: Consciousness

The Consciousness parameter of the Aldrete score evaluates the patient's level of awareness and ability to respond to commands.

A PACU patient who received spinal anesthesia complains of inability to move her legs 2 hours post-procedure. Which assessment finding would be most concerning?

Answer: Asymmetric motor block with increasing leg pain

Asymmetric motor block with increasing pain may indicate spinal hematoma or abscess, which are neurological emergencies requiring immediate evaluation.

During post-anesthesia assessment, a patient's blood pressure drops from 130/80 to 85/50 mmHg after repositioning to supine. The most appropriate initial nursing action is:

Answer: Increase IV fluid rate and notify anesthesia provider

Increasing IV fluid rate addresses potential hypovolemia and notifying the anesthesia provider ensures timely evaluation of a significant hemodynamic change.

A patient in the PACU following abdominal surgery has a urine output of 15 mL/hour for 2 consecutive hours. Which assessment finding would best help differentiate prerenal from intrinsic renal failure?

Answer: Urine sodium < 10 mEq/L

Urine sodium < 10 mEq/L indicates the kidney is reabsorbing sodium maximally, suggesting prerenal azotemia rather than intrinsic renal damage.

When assessing pain in a post-anesthesia patient with cognitive impairment, the PACU nurse should use which validated tool?

Answer: Pain Assessment in Advanced Dementia (PAINAD)

PAINAD is validated specifically for patients with cognitive impairment who cannot self-report pain, using behavioral indicators for assessment.

A post-anesthesia patient has ST-segment elevation in leads II, III, and aVF on telemetry. Which assessment finding would be most consistent with this ECG change?

Answer: Chest pain radiating to the jaw with diaphoresis

ST elevation in inferior leads (II, III, aVF) with jaw radiation and diaphoresis is classic for inferior wall myocardial infarction requiring immediate intervention.