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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:

Hemorrhoids are swollen veins in the anus and rectum that can cause pain, itching, and bleeding. Sitz baths are a common and effective treatment for hemorrhoids because they can help to:

Reduce inflammation and pain Promote healing

Relax the anal sphincter muscles Cleanse the anal area

Warm water helps to increase blood flow to the area, which can help to reduce swelling and inflammation. The water also helps to soothe and cleanse the irritated tissues.

Sitz baths are typically taken for 10-15 minutes at a time, several times a day. They can be taken in a bathtub or a special sitz bath basin that fits over a toilet seat.

Choice B rationale:

A fractured right arm would not benefit from a sitz bath. Sitz baths are specifically for treating the anal and rectal area.

Choice C rationale:

An abscessed tooth would not benefit from a sitz bath. Sitz baths are specifically for treating the anal and rectal area.

Choice D rationale:

Painful back muscle spasms would not benefit from a sitz bath. Sitz baths are specifically for treating the anal and rectal area.

A. Teach the patient to splint the incision when coughing to minimize pain. B. Assist the patient to sit up in the chair and ambulate in the hallway. C. Watch the patient use the incentive spirometer and ensure hourly usage. D. Dim the lights, provide warm blankets, and maintain a quiet environment. E. Maintain patient privacy and use therapeutic touch as desired by the patient.

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale:

Splinting the incision when coughing helps to minimize pain and discomfort, which can encourage deeper breathing and coughing. This is essential because deep breathing and coughing help to clear secretions from the lungs and prevent atelectasis (collapse of lung tissue).

Steps for splinting the incision:

Place a pillow or folded towel over the incision site.

Instruct the patient to apply gentle pressure to the pillow or towel with their hands when coughing or deep breathing. Encourage the patient to relax their abdominal muscles during coughing and deep breathing exercises.

Choice B rationale:

Sitting up in a chair and ambulating promote lung expansion and help to mobilize secretions. This is because gravity assists in moving secretions from the smaller airways into the larger airways, where they can be more easily coughed up.

Additional benefits of sitting up and ambulating: Improved circulation

Decreased risk of pneumonia Enhanced recovery from surgery Choice C rationale:

Using an incentive spirometer hourly helps to increase lung capacity and prevent atelectasis. The device encourages the patient to take slow, deep breaths, which helps to inflate the alveoli (air sacs) in the lungs.

Instructions for using an incentive spirometer:

Sit upright in a chair or bed.

Place the mouthpiece of the spirometer in your mouth and seal your lips around it.

Inhale slowly and deeply through the mouthpiece, aiming to raise the piston inside the device as high as possible. Hold your breath for 3-5 seconds.

Exhale slowly and completely through the mouthpiece.

Repeat the process 10-15 times per hour, or as instructed by your healthcare provider.

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The post-anesthesia care unit nurse receives a patient from the operating room. Which assessment will the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which patient would most likely benefit from a sitz bath?

Correct Answer is A

Explanation

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.)

Correct Answer is ["A","B","C"]

Explanation

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