Health history, allergies, current meds (anticoagulants, insulin, herbals)
Baseline vitals & labs; report abnormals
Teach deep breathing, incentive spirometer, coughing/splinting, leg exercises
Safety
Site marking; surgical 'time-out'
Pre-op meds; prophylactic antibiotics within 60 min of incision
NCLEX TipConfirm consent and NPO status pre-op, and teach deep breathing/incentive spirometry while the client is alert. Verify the surgical site with a time-out.
NCLEX TipIn the PACU, airway and breathing come first — anesthesia and opioids risk hypoventilation. Confirm the gag reflex before giving anything by mouth.
Prevent: incentive spirometer, deep breathing, ambulation
Circulatory / GI / GU
DVT / PE; hemorrhage / shock
Paralytic ileus (absent bowel sounds, distension)
Urinary retention (no void in 6–8h)
Monitor
Vital signs, I&O, wound, bowel sounds
Early mobilization prevents many complications
NCLEX TipAtelectasis is the most common cause of fever in the first 24–48h post-op. Early ambulation and incentive spirometry prevent most complications.
Cool the client; O₂; treat acidosis / dysrhythmias
Monitor closely
NCLEX TipMalignant hyperthermia: the earliest sign is a rising end-tidal CO₂. Stop the agent and give dantrolene. Always ask about family anesthesia reactions pre-op.
EVISCERATION: cover with sterile saline-soaked gauze
Keep client NPO; low-Fowler's with knees flexed
Notify the surgeon immediately (surgical emergency)
Stay with the client; monitor for shock
NCLEX TipFor evisceration, cover the organs with sterile saline-soaked gauze, position low-Fowler's with knees flexed, keep NPO, and call the surgeon immediately.
NCLEX TipPrevent post-op VTE with early ambulation, SCDs, and prophylactic anticoagulation. Never massage a suspected DVT — it can embolize to the lungs.
