1. The post anesthesia care unit (PACU) nurse transports the inpatient surgical

patient to the medical-surgical floor. 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 the patient require immediately post procedure?

a. Acute care—medical-surgical unit

b. Acute care—intensive care unit

c. Ambulatory surgery

d. Ambulatory surgery—extended stay