Skills and Competencies Flashcards

A PACU nurse notes that a patient's Foley catheter has had no output for 90 minutes post-operatively. After confirming catheter patency, the priority nursing action is:

Answer: Assess fluid balance and notify the anesthesia provider

Oliguria in the PACU may reflect inadequate fluid resuscitation, hypoperfusion, or surgical complications and requires provider notification after ensuring catheter function.

Which of the following represents the most appropriate pain reassessment interval after administering IV opioid analgesia in Phase I PACU?

Answer: 15–30 minutes or at peak effect of the medication

Reassessing pain at peak effect (typically 15–30 minutes for IV opioids) allows the nurse to evaluate treatment efficacy and plan further interventions safely.

A patient develops laryngospasm in the PACU immediately after extubation. The CPAN's first action should be:

Answer: Apply firm positive-pressure ventilation with 100% oxygen using a bag-valve-mask

Firm positive-pressure ventilation with 100% oxygen is the initial treatment for laryngospasm, as pressure may break the spasm and restore ventilation.

Post-dural puncture headache (PDPH) following spinal anesthesia is best characterized by:

Answer: Bifrontal or occipital headache that worsens with upright position and improves when supine

PDPH is a positional headache caused by CSF leakage through the dural puncture site; it worsens when upright and improves when lying flat.

A CPAN caring for a patient after total knee arthroplasty notes a sudden increase in heart rate to 130 bpm, SpO2 drop to 88%, and patient complaints of chest pain. The nurse should suspect:

Answer: Pulmonary embolism and prepare for emergent intervention

Pulmonary embolism is a known complication after orthopedic procedures; sudden tachycardia, hypoxia, and chest pain are classic presenting signs.

When assessing a patient for readiness to bypass Phase I recovery (Fast-Track criteria), the CPAN should confirm the patient has:

Answer: A modified Aldrete score of ≥9 with stable vital signs and no complications

Fast-track eligibility requires a modified Aldrete score of ≥9, indicating adequate recovery of activity, breathing, circulation, consciousness, and oxygenation.

A patient who had general anesthesia reports nausea and vomits 150 mL in the PACU. Which intervention is LEAST appropriate as a first-line response?

Answer: Administer promethazine 25 mg IV push

Promethazine IV push is associated with severe tissue injury and is contraindicated via this route; ondansetron and metoclopramide are safer first-line antiemetics.