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 D
Explanation
D. Difficulty or inability to abduct (raise out to the side) the arm at the shoulder is a classic finding in rotator cuff injuries, particularly in cases of significant tears or severe inflammation. This limitation in shoulder movement can be due to pain, weakness, or mechanical impingement caused by the injured rotator cuff.
A. The drop arm test is a physical examination maneuver used to assess for rotator cuff tears. In a negative drop arm test, the patient is able to slowly lower their arm from an abducted position (out to the side) to their side without significant pain or weakness. A negative test suggests that there may not be a complete tear of the rotator cuff.
B. Alteration in the contour of the shoulder joint could indicate various shoulder pathologies, including rotator cuff injuries. However, it is a nonspecific finding and can occur with other shoulder conditions as well.
C. Tinel's sign is a test used to assess for nerve compression or irritation. While it can be positive in conditions such as carpal tunnel syndrome, it is not typically associated with rotator cuff injuries.
Correct Answer is B
Explanation
B. If the patient expresses confusion or uncertainty about the surgical procedure, the nurse should notify the surgeon or appropriate healthcare provider promptly. The surgeon may need to revisit the discussion with the patient, clarify any misunderstandings, and answer any questions to ensure informed consent.
A. This option involves the nurse providing the patient with a comprehensive explanation of the planned surgical procedure, including the purpose, risks, benefits, and alternatives. That however, is the role of the provider.
C. While the operating room nurse may have knowledge about the planned surgical procedure, it is ultimately the responsibility of the surgeon or healthcare provider performing the procedure to ensure that the patient understands and consents to the surgery.
D. Administering preoperative antibiotics and managing sedative medications are important aspects of preoperative care but are not directly related to addressing the patient's concerns about understanding the planned surgical procedure.
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