CRITICAL THINKING EXERCISE:

How does the nurse assess the client for airway patency and adequate ventilation?
Answer:
 The nurse can assess the airway patency of the client by assessing voicing on exhalation,
listening for exhalation though the upper airway using a stethoscope, or by reading the
peak inspiratory pressure (PIP) and/or exhaled volumes via the ventilator. It can also be
assessed by evaluating for the presence or absence of obstructive signs or symptoms that
suggest the airway either is or may become obstructed. Signs and symptoms include such
findings as stridor with breathing, secretions, snoring, difficulty with inhalation and/or
exhalation, coughing, and changes in respiratory status, such as decreased oxygen
saturations. For the assessment of ventilation, the nurse will observe the client’s
respiratory rate (normal 12 to 20) and listen for clear breath sounds in the left and right
chest and sing end-tidal CO2 monitors. Auditory confirmation of breathing sounds is the
strongest sign of adequate ventilation.

1. What are the advantages of PCA (client-controlled analgesia)?

Answer:
Among the advantages of PCA over traditional administration of analgesics, either orally
or via intramuscular (IM) injection, include improved pain relief, greater patient satisfaction, less
sedation because they use less medicine. PCA enables the patient to move, turn, cough, and take
deep breaths with less pain, thus reducing postoperative pulmonary problems.

2. What measures can the nurse take to help the new postoperative client void?
Answer:
The nurse should:
 Encourage early ambulation and placement of a suprapubic hot pack has been shown to
reduce the risk of postoperative urinary retention.
 Encourage patient to void preoperatively to promote continence during low abdominal
surgery and to make abdominal organs more accessible.
 Assess urine output in closed drainage system or the patient’s urge to void and bladder
distention.
 Place call light, emesis basin, ice chips (if allowed), and bedpan or urinal within reach.

3. What is the Aldrete Scoring System, and why is it used postoperatively?

Answer:
The Aldrete scoring system is a method of clinically assessing the physical status of the
patient and readiness for transfer from the PACU to either the postsurgical ward or to the
second stage (Phase II) recovery area. This type of scoring system is used as a measurement
of recovery after anesthesia that includes gauging a patient's consciousness, activity,
respiration, and blood pressure. It is a criteria for a safe discharge from Phase I to Phase II of
post-anesthesia care.