CPAN Clinical Procedures and Protocols 3 — Questions and Answers
Question 1: A patient is admitted to the PACU following a thoracotomy with a chest tube to water-seal drainage. The nurse observes continuous bubbling in the water-seal chamber. This finding indicates:
- Normal drainage and should be documented
- An air leak that requires immediate notification of the surgeon (Correct answer)
- The chest tube needs to be clamped
- The suction level is set too high
Correct answer: An air leak that requires immediate notification of the surgeon
Continuous bubbling in the water-seal chamber indicates an ongoing air leak from the pleural space or at the chest tube insertion site, which requires surgical notification.
Question 2: Which pharmacologic agent is the drug of choice for treating bronchospasm in the PACU?
- Epinephrine 1:10,000 IV
- Albuterol via nebulizer or MDI (Correct answer)
- Methylprednisolone 125 mg IV
- Aminophylline 250 mg IV
Correct answer: Albuterol via nebulizer or MDI
Albuterol, a short-acting beta-2 agonist delivered via nebulizer or MDI, is the first-line pharmacologic treatment for bronchospasm due to its rapid onset and bronchodilatory effect.
Question 3: A PACU patient reports a pain score of 8/10 and has received maximum opioid doses per protocol. Which non-pharmacologic adjunct is MOST appropriate at this time?
- Distraction and deep breathing exercises (Correct answer)
- Application of heat to the surgical site
- Passive range of motion exercises
- Positioning the patient prone
Correct answer: Distraction and deep breathing exercises
Non-pharmacologic techniques such as distraction and guided deep breathing can reduce pain perception and anxiety when pharmacologic limits have been reached.
Question 4: During PACU assessment, a patient demonstrates confusion, hypertension, tachycardia, and diaphoresis after receiving meperidine. Which condition should the nurse suspect?
- Opioid overdose
- Serotonin syndrome (Correct answer)
- Neuroleptic malignant syndrome
- Emergence delirium
Correct answer: Serotonin syndrome
Meperidine can cause serotonin syndrome when combined with serotonergic medications; presenting symptoms include altered mental status, autonomic instability, and neuromuscular abnormalities.
Question 5: When assessing an epidural catheter in the PACU, the nurse notes the patient has no sensation or motor function below T4. The nurse's priority intervention is:
- Document the finding as expected after epidural placement
- Stop the epidural infusion and notify the anesthesia provider (Correct answer)
- Increase the epidural infusion rate to maintain analgesia
- Administer naloxone to reverse opioid effects
Correct answer: Stop the epidural infusion and notify the anesthesia provider
A high spinal or epidural block above T4 can compromise respiratory function and hemodynamic stability, requiring immediate cessation of the infusion and anesthesia notification.
Question 6: A post-thyroidectomy patient in the PACU develops inspiratory stridor, dysphagia, and neck swelling. The nurse's immediate priority is:
- Administer calcium gluconate 1 g IV
- Prepare for emergency airway management and alert the surgeon (Correct answer)
- Apply an ice collar to reduce swelling
- Elevate the head of bed and administer supplemental oxygen
Correct answer: Prepare for emergency airway management and alert the surgeon
Post-thyroidectomy stridor with neck swelling suggests hematoma-induced airway compromise, which is a surgical emergency requiring immediate airway preparation and surgeon notification.
Question 7: Which criterion must be met before a patient can be safely discharged from a Phase I PACU to Phase II or an inpatient unit?
- Patient must be fully awake and oriented to person, place, and time
- Patient must meet facility-approved discharge scoring criteria such as a Modified Aldrete Score of ≥9 (Correct answer)
- Patient must ambulate to the bathroom independently
- Patient must have resumed oral intake without nausea
Correct answer: Patient must meet facility-approved discharge scoring criteria such as a Modified Aldrete Score of ≥9
Discharge from Phase I PACU requires meeting a validated scoring threshold (e.g., Modified Aldrete ≥9) that ensures adequate recovery of vital functions per ASPAN standards.
CPAN Clinical Procedures and Protocols 3
A patient is admitted to the PACU following a thoracotomy with a chest tube to water-seal drainage.
The nurse observes continuous bubbling in the water-seal chamber.
This finding indicates: