Question

In the postanesthesia care unit (PACU), a patient's vital signs are blood pressure 116/72, pulse 74, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take first?

a. Place the patient in a side-lying position.
b. Encourage the patient to take deep breaths.
c. Prepare to transfer the patient to a clinical unit.
d. Increase the rate of the postoperative IV fluids.

Answer 1

The nurse in the PACU should first encourage the patient to take deep breaths to improve the oxygen saturation level, as SpO2 is slightly below the normal range.

Step-by-step explanation:

In the postanesthesia care unit (PACU), the presence of SpO2 at 91% is slightly below the normal range, which generally is above 92%. The fact that the patient is sleepy but can be easily awakened suggests that they are responsive, which is a positive sign. However, the priority is to address the potential for hypoxemia (low levels of oxygen in the blood). The nurse should first encourage the patient to take deep breaths to improve oxygenation. The other options are important but are secondary to ensuring the patient has adequate oxygen saturation.

It is part of the PACU nurse's duties to ensure that a patient's airway and the risk of aspiration have been evaluated. The nurse and anaesthesia professional must be aware of the patient's status during the immediate recovery phase and take appropriate actions. In this case, the action to encourage deep breaths is to prevent respiratory complications and promote better oxygen exchange.