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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Free Nursing Study Resources

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.

A. Mix the detemir and aspart in the same syringe, drawing up the aspart first. B. Mix the detemir and aspart in the same syringe, drawing up the detemir first. C. Draw up the aspart in one syringe and the detemir in another. D. Draw up the detemir in one syringe and the aspart in another.

Correct Answer is C

Explanation

Rationale for Choice A:

Mixing insulin detemir and insulin aspart in the same syringe is not recommended due to their differing physicochemical properties and potential for altered absorption and action profiles.

It's crucial to follow manufacturer guidelines, as mixing may lead to suboptimal glycemic control or unpredictable insulin activity.

Rationale for Choice B:

The order of mixing insulin detemir and insulin aspart, even if done incorrectly in the same syringe, would not significantly impact the overall contraindication of mixing them.

The primary concern remains the potential for altered pharmacodynamics and pharmacokinetics when these insulins are combined.

Rationale for Choice C:

Drawing up insulin aspart and insulin detemir in separate syringes is the correct procedure.

This approach ensures that each insulin maintains its intended action profile and absorption characteristics, leading to more predictable glycemic control.

It also aligns with best practices and guidelines for insulin administration.

Rationale for Choice D:

While drawing up insulin detemir first in a separate syringe is technically correct, it offers no specific advantage over drawing up insulin aspart first in a separate syringe.

The key principle is to avoid mixing the two insulins in the same syringe.

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

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Naxlex Comprehensive Predictor Exams

Which signs would suggest to a nurse that a patient is undergoing a stress response? (Choose all that apply)

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

Explanation

The patient is scheduled to receive insulin aspart and insulin detemir.What is the correct procedure for the nurse to draw up the insulins for administration?

Correct Answer is C

Explanation

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