What would you have answered?

[tbell2]

We had our first test in Med-Surg test last week. There was one question that had me and some of my classmates wondering. Let me know what you guys think

You are the recieving nurse accepting a patient to a med-surg floor from the PACU. What is the first thing you do?

A Check patient's level of consciousness

B See if patient's family is present

C Check patient's vital signs

D Order the patient dinner

For the record, I got the question wrong, asked the teacher the rationale and I am fine with it, although I still disagree. I am not going to fight a losing battle.

[Junebugfairy]

my first thought was asses vital signs, answer c.

vital signs are key.

daytonite, you really do kick 'tail' with the explanations.

i will say that for me the other answers definitely stood out as being incorrect.

[tbell2]

The answer was vitals.

I picked level of conscience. My line of thinking was I wouldn't take vitals and then go "Oh, wait! Are you in a coma?" I asked the instructor, she said ABCs ABCs ABCs

Glad to know I am alone in my line of thinking. Next test I will quietly chant to myself ABCs ABCs ABCs

[Natingale, EdD, RN]

tbell, see youre not the only one to think what you thought ...that was a good question

[icyounurse, BSN, RN]

Thats what I hate about these nursing school questions. In real life, you would simultaneously assess LOC and Vitals, they are both important and you can do both at the same time. Yeah its not unusual for a pt to be drowsy after anesthesia, but if they are unresponsive believe me you want to know immediately. They may need some Narcan.

[loricatus]

In reality, which is not the same as what you learn in school, the nurses assess LOC as we are in the hall transporting the pt from PACU to their room. Even before vitals, there is a dressing check to make sure there is no bleeding.

The patient can come to the floor with an Aldrete score of 8/10. The Aldrete score measures: 1-color (circulation) 2-BP (from baseline) 3-breathing 4-LOC (arousable, awake, unresponsive) 5-Movement of extremeities (no movement, moves 2 extremeties or moves all 4 extremities). The patient does not go to a med-surg floor until he/she is arousable to voice and vitals are stable.

The receiving nurse is actually concerned that something may have changed while the patient is being transported, so that is why the LOC and surgical site is checked first. The vitals are taken after the PACU nurse leaves the patient in the care of the med-surg nurse and has left the room.

Although your instructor is making sense according to the book way of nursing, I just wanted to reassure you that your thought process was in line with real world nursing practices I have encountered.

[Daytonite, BSN, RN]

All you Level of Consciousness supporters. . .I was a Med/Surg nurse for M-A-N-Y years. Patients coming out of PACU after general anesthesia are stoned! About the best some of them can do is open their eyes when you call their name. This is the Adrete Scoring scale which a patient must get a 9 out of 10 on to be discharged from PACU. Most get a 9 because they are usually never fully conscious after general anesthesia and only score a 1 for their level of consciousness.

Consciousness

2 = Fully awake

1 = Responds to name

0 = No response

Activity on command

2 = Moves all extremities

1 = Moves two extremities

0 = No movement

Respiration

2 = Free deep breathing

1 = Dyspneic, hyperventilating, obstructed breathing

0 = Apneic

Circulation

2 = Blood pressure within 20% of pre-op level

1 = Blood pressure within 50%-20% of pre-op level

0 = Blood pressure 50%, or less, of pre-op level

Oxygen saturation

2 = SpO2 >92% on room air

1 = Supplemental O2 required to maintain SpO2 >92%

0 = SpO 2

As a former supervisor and manager I can report that those who do not follow the principles of nursing as they are taught in school such as following the ABCs and the nursing process when problem solving end up the bane of their colleagues and eventually make errors that get found out and get them into trouble. I have seen and been part of the disciplinary process, and believe me, I am sure every one of the nurses who made mistakes had second thoughts about how the error happened. The time to develop a lifetime habit is while you are learning these principles in school. Listen to what your instructors are teaching you.

[Sarah Hay]

I am looking in my medical-surgical text book and these are the steps of admission from the postanesthesia care unit:

1. Record time of patient's return to unit

2. Take baseline vital signs

3. Assess pain and discomfort

4. Assess airway and breath sounds

5. Assess neurological status, including level of consiousness

6. Assess wound, dressing and drainage tubes

7. Assess color and appearance of skin

8. Assess urinary status

9. Position for maximal airway maintenance, comfort and safety

10. Check IV infusion

11. Call light within reach

12. Ensure tissues and emesis basin are within reach

13. Determine emotional condition

14. Check for family members

15. Check and carry out postoperative orders

Reference: Medical-Surgical Nursing, Lewis 2007 (p. 393)

I hope this helps!

:redpinkhe Sarah Hay, SN

[loricatus]

Patients do not go to the floor until they can respond to voice, which would be a 1 on the Aldrete score. They may be a bit 'stoned' from the narcotics but it would be unsafe to send a patient to the floor completely 'stoned.' Also, you have to take into account that the same anesthesia is used on day surgery patients who can go home after one hour in the recovery room-standard for all patients is an hour (longer if need be)-when phase II of the recovery process usually begins.

They can and do go to the floor with an 8 & home if a 9, under current AORN guidelines.

Also, the current Aldrete Score is a bit different from what was posted.

Here's a link to give a full overview of the current pre and perioperative process http://www.wlm-web.com/hcnet/TXFiles/tx009p.pdf

[loricatus]

I am looking in my medical-surgical text book and these are the steps of admission from the postanesthesia care unit:

1. Record time of patient's return to unit

2. Take baseline vital signs

3. Assess pain and discomfort

4. Assess airway and breath sounds

5. Assess neurological status, including level of consiousness

6. Assess wound, dressing and drainage tubes

7. Assess color and appearance of skin

8. Assess urinary status

9. Position for maximal airway maintenance, comfort and safety

10. Check IV infusion

11. Call light within reach

12. Ensure tissues and emesis basin are within reach

13. Determine emotional condition

14. Check for family members

15. Check and carry out postoperative orders

Reference: Medical-Surgical Nursing, Lewis 2007 (p. 393)

I hope this helps!

:redpinkhe Sarah Hay, SN

Kinda scary that they are teaching pain before the ABCs. I really feel sorry for the students because they seem to be in a Catch 22.

Best advise I can give is to follow the school's way to learn the basics and then find out hospital policy and adhere to that once you become a nurse.

The previously mentioned transfer procedures are part of the hospital policy, although they deviate from the textbook way. They were developed due to past incidents, as a way to correct process errors. If one were to deviate from the hospital policy and follow the textbook, they would be up for disciplinary action (as per a risk management directive).

[Do-over, ASN, RN]

Oh, those wacky nursing school exam questions... May I survive one more year of them!

[Sarah Hay]

Kinda scary that they are teaching pain before the ABCs. I really feel sorry for the students because they seem to be in a Catch 22.

Best advise I can give is to follow the school's way to learn the basics and then find out hospital policy and adhere to that once you become a nurse.

The previously mentioned transfer procedures are part of the hospital policy, although they deviate from the textbook way. They were developed due to past incidents, as a way to correct process errors. If one were to deviate from the hospital policy and follow the textbook, they would be up for disciplinary action (as per a risk management directive).

I understand that airway is like the number one thing you check for and I really do not know why the textbook says that. I am not employed at the moment and I just go to school full time. Our professor teaches almost 100% by the textbook and what she says goes. However, when employed at a medical institution you do follow their policy. I agree that one would be repremanded for not following hospital policy but when it comes to medical surgical exams, you answer what the textbook says.

:redpinkhe Sarah Hay, SN

[Silverdragon102, BSN]

In the real world we know things do change, however whilst still in nursing school you have to follow the text books and what you are taught.