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1. The postanesthesia care unit (PACU) nurse transports the inpatient surgical patient to the medical-surgicalfloor. Before leaving the floor, the medical-surgical nurse obtains a complete set of
vital signs. What is the rationale for this nursing action?
a. This is done to complete the first action in a head-to-toe assessment.
This is done to compare and monitor for vital sign variation during
b. transport.
This is done to ensure that the medical-surgical nurse checks on the
c. postoperative patient.
This is done to follow hospital policy and procedure for care of the
d. surgical patient.
ANS: B
Before the PACU nurse leaves the acute care area, the staff nurse assuming care for the patient takes a complete set of vital signs to compare with PACU findings. Minor vital sign variations normally occur
after
transporting the patient. The PACU nurse reviews the patient’s information with the medical-surgical nurse, including the surgical and PACU course, physician orders, and the patient’s condition. While
vital signs may or may not be the first action in a head-to-toe assessment, this is not the rationale for this situation. While following policy or ascertaining that the floor nurse checks on the patient are
good reasons for safe care, they are not the best rationale for obtaining vital signs.
2. The nurse is caring for a patient who will undergo a removal of a lung lobe. Which level of care will thepatient require immediately post procedure?
a. Acute care—medical-surgical unit
b. Acute care—intensive care unit
c. Ambulatory surgery
d. Ambulatory surgery—extended stay
ANS: B
Patients undergoing extensive surgery and requiring anesthesia of long duration recover slowly. If a patient is undergoing major surgery such as a procedure on the lung, a stay in the hospital and
specifically in the intensive care unit is required to monitor for potential risks to well-being. This patient would require more care than can be provided on a medical-surgical unit. It is not appropriate
for this type of patient to go home after the procedure or to stay in an extended stay area of an ambulatory surgery area because of the complexity and associated risks.
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