Patient Assessment and Evaluation Flashcards

A post-anesthesia patient reports severe nausea and has vomited twice. Which assessment finding would most influence the choice of antiemetic therapy?

Answer: Time elapsed since last antiemetic dose and agent used

Knowing the specific antiemetic already given and when it was administered guides selection of an agent from a different drug class to avoid redundant therapy.

During assessment of a patient after thyroid surgery, the PACU nurse notices inspiratory stridor and the patient clutches their throat. The priority intervention after calling for help is:

Answer: Open the surgical wound to relieve tracheal compression

Post-thyroid surgery stridor may indicate hematoma compressing the trachea; opening the wound to decompress is a life-saving emergency intervention while preparing definitive airway management.

A PACU patient who had general anesthesia has a temperature of 35.2°C (95.4°F). Which assessment finding warrants the most immediate intervention related to hypothermia?

Answer: Heart rate of 52 bpm with prolonged QT interval

Hypothermia-induced bradycardia with prolonged QT interval increases the risk of life-threatening dysrhythmias such as ventricular fibrillation, requiring urgent active rewarming.

When assessing a PACU patient's fluid status, which combination of findings is most consistent with fluid volume excess?

Answer: Hypertension, crackles on auscultation, jugular venous distension

Hypertension, pulmonary crackles, and jugular venous distension are classic signs of fluid volume excess resulting from impaired cardiac or renal handling of fluid.

A patient in the PACU after exploratory laparotomy has a nasogastric tube draining 400 mL of bright red blood in 30 minutes. Which assessment should the PACU nurse perform immediately?

Answer: Assess blood pressure, heart rate, and level of consciousness

Rapid assessment of hemodynamic status (blood pressure, heart rate, consciousness) identifies the degree of hemorrhagic compromise and guides urgency of escalation.

A pediatric patient in the PACU after tonsillectomy has a heart rate of 140 bpm, restlessness, and pallor. Which assessment finding would most distinguish postoperative hemorrhage from pain?

Answer: Frequent swallowing movements and emesis of dark red material

Frequent swallowing and emesis of dark blood after tonsillectomy are hallmark signs of post-tonsillectomy hemorrhage with the child swallowing pooled blood.

A PACU patient 1 hour after knee arthroplasty under spinal anesthesia has a blood pressure of 180/110 mmHg and complains of a throbbing headache. Which assessment question is most critical?

Answer: 'Is the headache worse when you sit up or lie flat?'

Post-dural puncture headache is positional (worse upright, relieved supine), and this distinction differentiates it from hypertensive headache, which has entirely different management.