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. 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.

A. Tympanic temperature 99.2° F (37.3° C) B. Fine crackles audible at both lung bases C. 200 mL sanguineous fluid in the wound drain D. Redness and swelling along the suture line

Correct Answer is C

Explanation

C. Excessive sanguineous fluid in the drain could indicate active bleeding or a hematoma formation, which are significant concerns after surgery. It should be reported to allow for appropriate intervention to prevent shock

A. A slight elevation in temperature can be expected in the immediate postoperative period due to the body's response to surgery (surgical stress response).

B. Fine crackles indicate the presence of fluid in the lungs, which could suggest complications such as pulmonary edema or atelectasis. While this finding warrants monitoring and intervention, it may not be the most critical issue to report to the surgeon in this context.

D. Redness and swelling along the suture line can indicate inflammation or infection at the surgical site. This is a normal response of the tissues to trauma such as surgery.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon?

Correct Answer is C

Explanation

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