The post-anesthesia care unit nurse receives a patient from the operating room. Which assessment will the nurse perform first?
Check intravenous lines for patency or redness.
Check nasogastric tube and presence of bowel sounds.
Check airway, lung sounds, and pulse oximetry.
Check Foley catheter and surgical fluid intake.
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Inaccurate statement: While herbal supplements are derived from plant materials, this does not inherently guarantee their safety or non-toxicity. Some plants contain potent compounds that can have adverse effects, even in small doses.
Lack of regulation: Herbal supplements are not regulated by the FDA in the same way as prescription medications. This means that there is no guarantee of their purity, potency, or consistency.
Potential for interactions: Herbal supplements can interact with prescription medications, potentially leading to harmful side effects.
Choice B rationale:
Cost-related issue: The cost of herbal supplements can vary widely. While some may be less expensive than prescription medications, others can be quite costly.
Misleading focus: Emphasizing cost as a primary factor could lead patients to prioritize affordability over safety and effectiveness.
Choice C rationale:
Addresses quality concerns: This response directly addresses the lack of stringent quality standards for herbal supplements, highlighting a significant safety concern.
Encourages informed decision-making: This response encourages patients to carefully consider the potential risks and benefits of herbal supplements, prompting them to seek reliable information and discuss their choices with healthcare providers.
Choice D rationale:
Convenience vs. safety: While the convenience of herbal supplements may be appealing, this response does not address the potential safety concerns associated with their use.
Potential for misuse: Highlighting convenience could lead to patients using herbal supplements inappropriately or without necessary guidance from healthcare professionals.
Correct Answer is ["B","C","E"]
Explanation
Choice B rationale:
Heart rate: During a stress response, the sympathetic nervous system is activated, leading to a release of hormones such as adrenaline and cortisol. These hormones increase heart rate, preparing the body for a "fight or flight" response. A heart rate of 132 beats per minute is significantly elevated compared to a normal resting heart rate of 60-100 beats per minute, suggesting a stress response.
Choice C rationale:
Pupil dilation: Pupil dilation is another physiological change associated with the activation of the sympathetic nervous system during stress. The dilation allows more light to enter the eyes, enhancing visual acuity and awareness of surroundings, which can be helpful in responding to potential threats.
Choice E rationale:
Difficulty sleeping: Stress can negatively impact sleep in several ways. It can cause racing thoughts, anxiety, and physical tension, making it difficult to fall asleep and stay asleep. Sleep disturbances are a common symptom of stress and can further exacerbate its effects.
Rationale for incorrect choices:
Choice A: Blood glucose level can be affected by stress, but a low blood glucose level of 36 mg/dL is more likely to be due to other causes such as hypoglycemia or insulin therapy. It's not a direct indicator of a stress response.
Choice D: Blood pressure can increase during stress, but a blood pressure of 104/56 mmHg is within the normal range and does not necessarily indicate a stress response.
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