ABPANC ABPANC Anesthesia Recovery & Phase Management 2 — Questions and Answers
Question 1: What nursing intervention is most appropriate for a patient exhibiting post-operative shivering in the PACU?
- Apply warm blankets and consider meperidine per protocol (Correct answer)
- Administer antipyretics to reduce core temperature
- Restrict fluids to prevent fluid overload
- Elevate the head of bed to 90 degrees
Correct answer: Apply warm blankets and consider meperidine per protocol
Warm blankets address heat loss and meperidine (Demerol) is effective in reducing post-operative shivering via kappa-opioid receptor activity.
Question 2: Which assessment finding in a PACU patient most warrants immediate notification of the anesthesia provider?
- Mild nausea without vomiting
- SpO2 88% unresponsive to supplemental oxygen (Correct answer)
- Complaint of thirst
- Temperature of 36.2°C (97.2°F)
Correct answer: SpO2 88% unresponsive to supplemental oxygen
SpO2 88% unresponsive to supplemental oxygen indicates a serious respiratory compromise requiring immediate anesthesia provider intervention.
Question 3: A patient recovering from spinal anesthesia has a sensory level at T6. What complication should the PACU nurse prioritize monitoring for?
- Urinary retention and hypotension (Correct answer)
- Hypertension and tachycardia
- Hyperglycemia and wound dehiscence
- Respiratory alkalosis and tetany
Correct answer: Urinary retention and hypotension
High spinal levels can cause sympathetic blockade leading to hypotension and bladder dysfunction requiring urinary retention monitoring.
Question 4: Which patient position is most appropriate for a patient suspected of having post-dural puncture headache after spinal anesthesia?
- High Fowler's position to reduce CSF pressure
- Supine position to reduce headache symptoms (Correct answer)
- Left lateral with knees to chest
- Reverse Trendelenburg at 30 degrees
Correct answer: Supine position to reduce headache symptoms
Post-dural puncture headache classically worsens with upright positioning and improves when the patient lies supine due to CSF pressure changes.
Question 5: When assessing a patient's emergence from general anesthesia, what is the significance of the train-of-four (TOF) ratio?
- It measures the depth of inhalational anesthesia
- It indicates the degree of neuromuscular blockade reversal (Correct answer)
- It assesses the patient's level of consciousness
- It monitors the cardiac rhythm after anesthesia
Correct answer: It indicates the degree of neuromuscular blockade reversal
A TOF ratio ≥0.9 indicates adequate reversal of neuromuscular blockade and acceptable neuromuscular function for extubation.
Question 6: What is the priority nursing action when a PACU patient's blood pressure drops to 80/50 mmHg immediately post-operatively?
- Administer oral fluids and reassess in 15 minutes
- Assess for cause, notify provider, and initiate IV fluid bolus per protocol (Correct answer)
- Apply a knee-chest position and administer epinephrine auto-injector
- Document the finding and recheck blood pressure in 30 minutes
Correct answer: Assess for cause, notify provider, and initiate IV fluid bolus per protocol
Hypotension requires immediate assessment for cause, provider notification, and IV fluid administration to restore perfusion per standing protocol.
ABPANC ABPANC Anesthesia Recovery & Phase Management 2
What nursing intervention is most appropriate for a patient exhibiting post-operative shivering in the PACU?