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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

B. Repositioning the client regularly is an important intervention to prevent pressure ulcers and pressure points, especially when the client is immobilized in traction. Repositioning helps distribute pressure evenly on different areas of the body, reducing the risk of tissue ischemia and pressure-related injuries around the edges of the splint.

A. Lotions or moisturizers can increase the risk of skin breakdown and infection, especially when applied under medical devices such as splints or casts.

C. Removing the weights for a few minutes each hour is not necessary to prevent pressure points around the edges of the splint. Balanced skeletal traction is typically applied to maintain continuous traction force on the fractured femur for therapeutic purposes.

D. Applying a foot plate to the bed is not directly related to preventing pressure points around the edges of the splint. Foot plates are typically used to prevent foot drop and maintain proper alignment of the foot and ankle joints.

A. The ropes are securely attached to the pins. B. The weights are equal on each side. C. The weights rest against the foot of the bed. D. The ropes are in the center of the wheel grooves.

Correct Answer is C

Explanation

C. The weights in skeletal traction should not rest against the foot of the bed. Placing the weights on the floor or using a weight-bearing device such as a frame or stand is necessary to provide countertraction and maintain proper tension on the traction system.

A. In skeletal traction, the ropes or cables should be securely attached to the pins that are inserted into the bone. Proper attachment ensures that the traction force is applied effectively and safely.

B. In balanced skeletal traction, the weights on each side of the traction setup should be equal to maintain proper alignment and traction force. Balanced traction helps prevent unequal forces on the bone and surrounding tissues.

D. The ropes or cables should be properly positioned in the center of the wheel grooves to ensure smooth movement of the weights and prevent binding or friction. Proper alignment of the ropes reduces the risk of malfunction or damage to the traction equipment.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a prescription for balanced skeletal traction with a Thomas splint for the treatment of a fractured femur. Which of the following interventions should the nurse implement to prevent pressure points from developing around the edges of the splint?

Correct Answer is B

Explanation

A nurse is assessing a client who is in skeletal traction. The nurse should correct which of the following findings?

Correct Answer is C

Explanation

A nurse is providing care for four clients on a medical-surgical unit, Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply.)

A nurse is caring for a client who has a fractured right femur and is in balanced suspension traction. The client is reporting pain from muscle spasms. Which of the following actions should the nurse take first?

The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I don't understand what the doctor said about the surgery." Which action should the nurse take next?

A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occurs?

A nurse notes increasing edema in the calf of a client who has multiple fractures of the leg. The nurse should recognize that increasing edema is a manifestation of which of the following complications?

A nurse is teaching a newly licensed nurse about the difference between a plaster cast and a synthetic cast. Which of the following information should the nurse include in the teaching?

A patient is admitted to the postanesthesia care unit (PACU) with a blood pressure (BP) 122/72 mm Hg. Thirty minutes after admission, the BP is 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate?

A nurse is developing a plan of care for a client who has a fracture to achieve the outcome of functional healing. To assist in meeting this goal, which of the following nursing interventions is the highest priority?