FREE ABPANC Safety Needs Questions and Answers
A nurse in the PACU is caring for a post-operative patient who is drowsy but responsive. The nurse notices the side rails are down, and the patient begins to move. What is the nurse’s immediate action?
Ensuring the side rails are up helps prevent falls, which are a significant safety risk in drowsy post-operative patients. Providing a call light promotes safe communication with the nursing staff. Physical restraints are unnecessary unless absolutely indicated and may cause additional stress.
While caring for a patient receiving IV opioid pain medication, the nurse observes that the patient’s respiratory rate has dropped to 8 breaths per minute. What is the nurse’s priority intervention?
A respiratory rate of 8 breaths per minute indicates opioid-induced respiratory depression. Naloxone, an opioid antagonist, must be administered immediately to reverse the effects of opioids and prevent hypoxia. Increasing oxygen alone does not address the underlying cause.
The nurse prepares to transport a patient from the PACU to the surgical floor. Which of the following is most important to verify before transport?
Before transport, the patient’s airway stability and vital signs must be stable to ensure their safety during transfer. Pain management and family notification are important but secondary considerations.
A patient recovering from surgery becomes restless and tries to remove their IV catheter. What is the nurse’s best action?
Restlessness and agitation may result from pain, hypoxia, or delirium post-anesthesia. The nurse must first assess for underlying causes and reorient the patient as needed. Restraints or sedation should only be considered if the behavior persists and poses harm.
During a post-operative assessment, the nurse notices a small pool of blood forming under the patient’s surgical dressing. What is the nurse’s immediate action?
Reinforcing the dressing maintains sterility while managing minor bleeding. Removing the dressing risks contamination and disrupting the clotting process. The surgeon should be notified for further evaluation and intervention as necessary.