An unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU) 15 minutes ago has an oxygen saturation of 89%. Which action should the nurse take first?
Increase the oxygen flowrate.
Elevate the patient's head on two pillows.
Suction the patient's mouth.
Perform the jaw-thrust maneuver.
The Correct Answer is A
A. The most appropriate first action would be to increase the oxygen flowrate to improve the patient's oxygen saturation levels. This intervention directly addresses the hypoxemia and can help prevent further complications related to low oxygen levels in the blood.
B. Elevating the patient's head can help improve ventilation and oxygenation. By raising the head, the patient's airway may become more patent, allowing for better airflow and oxygen exchange in the lungs. However, this should follow oxygenation.
C. Suctioning the patient's mouth aims to remove any secretions or obstructions that may be compromising the airway and contributing to the low oxygen saturation. However, this should follow oxygenation.
D. This maneuver can be helpful if the airway is obstructed by the tongue or soft tissues, potentially improving ventilation and oxygenation. However, this should follow oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Phalen's sign is a test for carpal tunnel syndrome. It is positive when the client experiences numbness, tingling, or pain in the median nerve distribution (especially the thumb, index finger, middle finger, and half of the ring finger) within 1 minute of wrist flexion.
A. Cool extremities are not typically associated with carpal tunnel syndrome. They may indicate issues related to circulation rather than compression of the median nerve.
C. Trousseau's sign is a test for latent tetany, which is associated with hypocalcemia. It involves inflating a blood pressure cuff on the upper arm and observing for carpal spasm. It is not a manifestation of carpal tunnel syndrome.
D. A decreased radial pulse may indicate vascular issues or compression of the radial artery, not carpal tunnel syndrome.
Correct Answer is B
Explanation
B. Immediate-release morphine provides rapid pain relief and can effectively address breakthrough pain. The dose of 30 mg is reasonable given the severity of the pain.
A. Lorazepam is a benzodiazepine used to treat anxiety. While it may help with anxiety, it does not directly address the severe breakthrough pain experienced by the patient.
C. Amitriptyline is a tricyclic antidepressant used to treat neuropathic pain and depression. While it may help with chronic pain management, it is not appropriate for providing rapid relief for breakthrough pain or acute anxiety.
D. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) commonly used for mild to moderate pain relief and inflammation. However, it is not typically used for severe breakthrough pain, especially in a patient already receiving opioid therapy.
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