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Situational Set 1 – Nurse G is assigned in the morning shift of the Post-Anesthesia Care Unit (PACU) and has a patient for admission.

1. The INITIAL priority assessment performed by the nurse, when admitting a patient in the unit after abdominal surgery is to check for __________.

A. Surgical site for drainage and hemorrhage

C. Responsiveness to painful stimuli and noise

B. Skin color and temperature

D. Respiratory function and airway

2. How should the nurse position the patient who is in a somnolent status and still under the effect of anesthesia?

A. Supine position with head bed slightly elevate.

B. Prone position with a pillow under the abdomen.

C. Semi-Flower’s position with the head turned to the right.

D. Left lateral position with a pillow supporting the head.

3. When a patient has bleeding after surgery, the PACU nurse, expects which color if coming from the arterial source?

A. Darkly colored, blood flows fast.

B. Bright red and spurts with the heartbeat.

C. Slow, dark colored, generally ooze.

D. Pinkish colored slowly flowing.

4. During the immediate post-operative phase, the PRIMARY goal of the health care team is to maintain ventilation. Which of the following situations should be observed as a result of hypoxemia?

A. Excess carbon dioxide in the blood.

B. Increasing ammonia in the blood.

C. Decreased oxygen saturation.

D. Reduction of blood PH.

5. When a patient develops a temperature of 39.8 degree centigrade after an abdominal surgery with an ongoing blood transfusion, the PACU nurse should notify the surgeon as this may indicate ___________.

A. Abdominal tissue injury

B. On-going potential infection

C. Post-anesthesia drug reaction

D. Allergic reaction from blood transfusion