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 patient reports abdominal pain when ambulating. B. The patient has fluid intake 600 mL greater than the output. C. The patient's calf is swollen and warm to touch. D. The patient's temperature is 100.3° F (37.9° C).

Correct Answer is C

Explanation

C. The patient's calf being swollen and warm to touch is concerning for a possible deep vein thrombosis (DVT), a clot formation in the deep veins of the leg. DVT is a serious complication post-surgery that requires immediate attention to prevent the clot from dislodging and causing a pulmonary embolism (PE), which can be life-threatening.

A. Abdominal pain after a total abdominal hysterectomy is common and can be expected due to the surgical incision and manipulation of abdominal tissues.

B. Fluid balance is important postoperatively to prevent complications like dehydration or fluid overload. A significant imbalance, with intake substantially greater than output, could indicate issues which may require intervention. However, this is not as urgent as a client with likely DVT.

D. A slight increase in temperature is common in the immediate postoperative period due to the body's response to tissue injury. While it could indicate infection, it's not necessarily alarming on its own.

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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

The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider?

Correct Answer is C

Explanation

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