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 A
Explanation
Choice A rationale:
Shearing force is the primary factor that contributes to the formation of pressure injuries when a patient's body slides downward. It occurs when two surfaces move in opposite directions, causing stress and strain on the tissues between them.
Compression of Tissues: When the patient's body slides downward, the skin and underlying tissues are compressed between the bony prominences (such as the sacrum or heels) and the surface of the bed. This compression restricts blood flow to the area, depriving the tissues of oxygen and nutrients.
Tissue Stretching and Tearing: As the body slides, the skin and underlying tissues are also stretched and pulled in opposite directions. This shearing force disrupts the normal alignment of cells and tissues, leading to microscopic tears and damage.
Impaired Blood Flow: Shearing force further compromises blood flow by stretching and compressing blood vessels. This reduces the delivery of oxygen and nutrients to the tissues, while also hindering the removal of waste products.
Tissue Damage and Necrosis: The combination of compression, stretching, and impaired blood flow leads to cell death and tissue necrosis. This is the hallmark of pressure injuries, which can range from superficial blisters to deep ulcers that extend into muscle and bone.
Factors that Increase Shearing Force: Certain factors can increase the risk of shearing force and pressure injury development, including:
Increased moisture (from sweat or incontinence) Decreased mobility
Poor skin integrity
Malnutrition
Friction from bedsheets
In conclusion, shearing force is the main factor that contributes to pressure injury formation when a patient's body slides downward. It disrupts blood flow, damages tissues, and can lead to significant wounds.
Correct Answer is D
Explanation
Choice A rationale:
Soaking the wound in an Epsom salt solution is not recommended for abscessed wounds. While Epsom salt has some potential benefits for wound healing, such as reducing inflammation and drawing out fluids, it can also be irritating to the skin and may actually worsen the abscess. Additionally, there's a risk of introducing bacteria from the Epsom salt into the wound, which could lead to further infection.
Choice B rationale:
Administering warm water sitz baths is not directly applicable to an abscessed leg wound. Sitz baths are typically used for conditions affecting the perineal area, such as hemorrhoids or postpartum discomfort. They may help to soothe and cleanse the affected area, but they would not be effective in treating an abscess on the leg.
Choice C rationale:
Applying cold moist compresses is not the most appropriate intervention for an abscessed wound. Cold compresses can help to reduce pain and inflammation, but they can also constrict blood vessels and potentially hinder the healing process. Warm compresses are generally preferred for abscesses because they can help to promote drainage and healing.
Choice D rationale:
Applying warm moist compresses is the most appropriate nursing intervention for an abscessed leg wound. Warm compresses have several beneficial effects:
They promote vasodilation, which increases blood flow to the area and helps to deliver white blood cells and other healing agents to the site of infection.
They help to soften and loosen hardened pus, making it easier for the abscess to drain.
They provide a moist environment that promotes healing and prevents the wound from drying out. They can help to reduce pain and inflammation.
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