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 C

Explanation

C. A neurovascular assessment involves evaluating the circulation, sensation, and movement of the limb distal to the cast to ensure there are no signs of neurovascular compromise, such as decreased pulses, numbness, tingling, or weakness. Prompt identification of any neurovascular impairment is essential for preventing complications such as compartment syndrome.

A. Explaining discharge instructions is important for ensuring the client and their parents understand how to care for the cast at home. However, it is not the priority action.

B. Applying an ice pack to the casted leg can help reduce swelling and provide pain relief, but it is not the priority action immediately after the cast application.

D. Providing reassurance is important for alleviating anxiety and promoting a positive experience for the client and their parents. However, it is not the priority action.

A. Continue to take vital signs every 15 minutes. B. Notify the anesthesia care provider (ACP). C. Increase the postoperative IV fluid rate. D. Administer oxygen therapy at 100% per mask.

Correct Answer is A

Explanation

A. Vital sign monitoring every 15 minutes is a standard practice in the postanesthesia care unit (PACU) to closely monitor the patient's hemodynamic status and response to anesthesia. However, in this scenario, the patient's blood pressure (BP) and other vital signs are within an acceptable range, and there are no signs of instability.

B. The patient's vital signs, including BP, pulse rate, and skin condition, are within normal limits. There are no indications of hemodynamic instability or adverse events.

C. There is no indication to increase the postoperative intravenous (IV) fluid rate based solely on the patient's stable vital signs and absence of signs of dehydration or hypovolemia. Increasing IV fluids without clinical indication may lead to fluid overload and potential complications.

D. The patient's oxygen saturation level is not provided in the scenario, and there are no signs or symptoms of respiratory distress or hypoxemia. Therefore, administering oxygen therapy at 100% per mask is not warranted at this time.

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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 an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take?

Correct Answer is C

Explanation

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?

Correct Answer is A

Explanation

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