Patient Assessment and Evaluation Flashcards

A PACU nurse is evaluating a patient for discharge using the Post-Anesthetic Discharge Scoring System (PADSS). Which criterion must score at least 2 points for safe discharge?

Answer: Vital signs within 20% of preoperative baseline

PADSS requires vital signs to be within 20% of preoperative baseline to score 2 points, reflecting hemodynamic stability for safe discharge.

During assessment of a patient who received epidural analgesia, the nurse notes blood pressure 88/54 mmHg, heart rate 58 bpm, and a sensory block at T4. Which intervention addresses the primary mechanism of hypotension?

Answer: Administer ephedrine 5-10 mg IV for vasodilation

High thoracic epidural block causes sympathetic vasodilation; ephedrine provides alpha and beta adrenergic support to counteract neuraxial-induced hypotension effectively.

A patient in Phase II PACU following laparoscopic surgery complains of right shoulder pain rated 7/10 despite adequate incisional analgesia. This finding is best explained by:

Answer: Referred pain from residual diaphragmatic irritation by CO2

Residual CO2 used for pneumoperitoneum irritates the diaphragm, causing referred pain to the ipsilateral shoulder via the phrenic nerve.

A PACU nurse assesses a patient who suddenly develops unilateral arm weakness, facial droop, and slurred speech 40 minutes post-carotid endarterectomy. The priority action is:

Answer: Immediately notify the surgeon and anesthesia provider

Post-carotid endarterectomy neurological deficits may require emergent return to the OR; immediate notification of the surgical team is the priority action.

When assessing pain in a non-verbal intubated PACU patient, which behavioral indicator on the Critical Care Pain Observation Tool (CPOT) receives the highest score?

Answer: Patient fights the ventilator and coughs frequently

Fighting the ventilator or coughing on the endotracheal tube scores 2 on the CPOT ventilator compliance subscale, indicating the highest level of distress in that domain.

A patient in the PACU who received ketamine as part of the anesthetic reports seeing frightening visions and is extremely agitated. The most appropriate assessment priority is:

Answer: Rule out hypoxia and hypercapnia as contributing factors before treating

Before attributing symptoms to ketamine dysphoria, hypoxia and hypercapnia must be ruled out as they can cause identical presentations and require different treatment.

A 55-year-old male in the PACU after prostatectomy has an indwelling urinary catheter with output of 250 mL/hr of clear yellow urine. His blood pressure is 155/95 mmHg and heart rate is 88 bpm. Which assessment is most important to perform next?

Answer: Evaluate serum sodium level for hyponatremia

High urine output after prostate surgery with hypertension may indicate absorption of hypotonic irrigating fluid causing TURP syndrome with dilutional hyponatremia.