The nurse is caring for a patient with shallow respirations and diminished breath sounds following abdominal surgery yesterday.


Which are the appropriate actions of the nurse? (Select all that apply.)

Choice A rationale:

Incorrect because swallowing the tablet with water would lead to slower absorption and a delayed onset of action. Nitroglycerin is rapidly absorbed through the oral mucosa, and swallowing it would route it through the digestive system, where it would be absorbed more slowly and less effectively.

Swallowing the tablet could also increase the risk of side effects, such as headache and flushing, due to the larger amount of the drug that would be absorbed systemically.

Choice B rationale:

Incorrect because crushing the tablet and dissolving it in water would also delay its absorption. This method would require the tablet to dissolve in the water before it could be absorbed through the oral mucosa, which would slow down the onset of action.

Crushing the tablet could also damage the medication and make it less effective.

Choice C rationale:

Incorrect because placing the tablet in the patient's mouth next to the cheek would not allow for optimal absorption. The oral mucosa under the tongue is more permeable than the cheek, so placing the tablet under the tongue allows for faster and more efficient absorption.

Placing the tablet in the cheek could also increase the risk of the patient accidentally swallowing it.

Choice D rationale:

Correct because placing the tablet under the patient's tongue allows for rapid absorption and a quick onset of action. The sublingual route is the preferred method of administration for nitroglycerin because it allows the medication to bypass the digestive system and be absorbed directly into the bloodstream.

This method also allows for the patient to easily remove the tablet if they experience any side effects.

Choice A rationale:

While checking intravenous lines for patency and redness is important, it's not the most immediate priority in the post- anesthesia care unit (PACU). Ensuring airway patency and adequate oxygenation takes precedence over IV assessment. Issues with IV lines can usually be addressed quickly if they arise, whereas compromised airway or breathing can rapidly lead to life- threatening complications.

Choice B rationale:

Assessment of nasogastric tubes and bowel sounds is also important, but it's not as urgent as checking the airway and breathing. Bowel sounds may be absent immediately after surgery due to anesthesia and bowel manipulation, and their presence or absence doesn't necessarily indicate an immediate problem. Similarly, nasogastric tubes can be checked and adjusted as needed after ensuring the patient's airway and breathing are stable.

Choice D rationale:

Checking the Foley catheter and surgical fluid intake is essential for monitoring fluid balance and renal function, but it's not a priority over assessing airway, breathing, and circulation (ABCs). Fluid status can be assessed and managed after ensuring the patient's respiratory and circulatory systems are functioning adequately.

Choice C rationale:

Checking the airway, lung sounds, and pulse oximetry is the most critical assessment in the PACU because it ensures that the patient is breathing effectively and has adequate oxygen saturation. This assessment addresses the primary ABCs of patient care:

Airway: The nurse will assess for any obstructions or potential for obstruction, such as swelling, secretions, or the tongue blocking the airway. They will also ensure proper positioning of the head and neck to maintain airway patency.

Breathing: The nurse will listen to lung sounds to evaluate air entry and identify any signs of respiratory distress, such as wheezing, crackles, or decreased breath sounds. They will also monitor respiratory rate and effort.

Circulation: Pulse oximetry measures oxygen saturation in the blood, providing a quick and non-invasive assessment of oxygenation status. It's essential to ensure adequate oxygen delivery to tissues and organs.

By prioritizing the assessment of airway, lung sounds, and pulse oximetry, the nurse can quickly identify and intervene in any respiratory or oxygenation issues, preventing potentially life-threatening complications.