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. This test is known as Phalen's maneuver. It involves holding the wrist in flexion for 60 seconds or more to compress the median nerve, which runs through the carpal tunnel in the wrist. Reproduction of symptoms, such as numbness and tingling, during this maneuver is considered a positive sign for carpal tunnel syndrome.
A. Flexing the arm at the elbow doesn't directly assess for carpal tunnel syndrome. This movement primarily involves the elbow joint and the muscles of the upper arm.
C. Extending the arm upward doesn't directly assess for carpal tunnel syndrome. This movement primarily involves the shoulder joint and muscles of the upper arm.
D. Holding the arm straight doesn't directly assess for carpal tunnel syndrome. This movement primarily involves the elbow joint and muscles of the upper arm.
Correct Answer is B
Explanation
B. Methamphetamine use can cause significant cardiovascular effects, including tachycardia, hypertension, and arrhythmias. Given the patient's presentation with an irregular heart rate and tachycardia, continuous cardiac monitoring through an ECG is essential to assess for any life-threatening arrhythmias or other cardiac complications.
A. Reorientation is important for patients who are disoriented, but in the case of a patient who has admitted to using methamphetamine and is exhibiting signs of agitation and tachycardia, the priority is to ensure the patient's safety and stabilize their condition.
C. While providing a calm environment is beneficial for patients who are agitated, it is not the most important action in this scenario.
D. Obtaining a comprehensive health history, including prior drug use, is important for understanding the patient's background and potential risk factors. However, in this acute situation where the patient is disoriented, agitated, and exhibiting signs of cardiovascular distress, the priority is to address the immediate medical needs and stabilize the patient's condition.
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