Which is the priority initial assessment for a patient who is admitted to the post anesthesia care unit (PACU) after surgery with general anesthesia?
Temperature
Heart rate
Respirations
Blood pressure
The Correct Answer is C
A. Temperature: While temperature monitoring is important, hypothermia is not the most immediate concern after general anesthesia.
B. Heart rate: Although heart rate should be monitored, it is not the first priority in assessing an anesthetized patient.
C. Respirations: Airway and breathing are the top priorities in the PACU. General anesthesia can depress respiratory function, increasing the risk of airway obstruction or hypoventilation. Ensuring adequate ventilation is the first step in assessment.
D. Blood pressure: Blood pressure is important but secondary to airway and breathing in the initial assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Discontinue suctioning and administer 100% oxygen: A drop in oxygen saturation and bradycardia indicates the patient is not tolerating suctioning. The priority is to stop suctioning and administer 100% oxygen to prevent hypoxia.
B. Discontinue suctioning and prepare for resuscitation: While severe cases may require resuscitation, the immediate intervention is oxygen administration, not premature resuscitation efforts.
C. Continue suctioning and administer 50% oxygen: Continuing suctioning may worsen hypoxia and bradycardia. Administering 50% oxygen may not be sufficient in a critical situation.
D. Continue suctioning and administer prescribed epinephrine: Epinephrine is used for anaphylaxis and severe cardiac issues, not for managing suction-related hypoxia.
Correct Answer is D
Explanation
A. "Check your oxygen equipment once each week.": Oxygen equipment should be checked daily for proper function and leaks, not just weekly.
B. "Use wool blankets on your bed.": Wool and synthetic fabrics generate static electricity, which can ignite oxygen. Cotton blankets should be used instead.
C. "Store unused oxygen tanks horizontally.": Oxygen tanks should always be stored upright and secured to prevent tipping over.
D. "Do not adjust the oxygen flow rate.": Clients should not change the oxygen flow rate unless instructed by the provider, as improper adjustments can cause oxygen toxicity or hypoxia.
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