A client is being transferred to the medical-surgical unit from the PACU after receiving general anesthesia for a procedure. Which of the following actions is the priority for the nurse when the client arrives on the unit?

Assess airway patency

Check the dressing to assess bleeding.

Check tubes or drains for patency.

Assess all vital signs.

Answer and Explanation

The Correct Answer is A

A. Assess airway patency: Ensuring the airway is patent is the highest priority because compromised airway patency can lead to life-threatening respiratory complications. This is the first step in the ABCs (Airway, Breathing, Circulation) of emergency and postoperative care.
B. Check the dressing to assess bleeding: While assessing the dressing for bleeding is important, it is secondary to ensuring the client has a patent airway. Uncontrolled bleeding can be addressed after confirming the client can breathe adequately.
C. Check tubes or drains for patency: Checking tubes and drains for patency is also important, but it should be done after ensuring the client's airway is secure. This step is essential for preventing complications but is not as immediately critical as airway assessment.
D. Assess all vital signs: Assessing vital signs is crucial, but it follows after ensuring airway patency. Vital signs provide comprehensive information about the client's status, but an obstructed airway must be addressed first to ensure effective breathing and oxygenation.

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Correct Answer is A

Explanation

A. Hypocalcemia: Hypocalcemia can cause signs such as muscle twitching, spasms, or tetany, which could be observed in the upper extremity and might be noted during a blood pressure measurement.
B. Hypokalemia: While hypokalemia can cause muscle weakness and cramping, it is less directly associated with specific upper extremity signs compared to hypocalcemia.
C. Hypophosphatemia: This generally affects energy levels and muscle function but is less commonly associated with immediate and visible upper extremity signs.
D. Hyponatremia: This primarily affects fluid balance and mental status, and is less likely to present with specific upper extremity findings during a blood pressure check.

A. Pulmonary embolism B. Pneumonia C. Hemorrhage D. Myocardial infarction

Correct Answer is A

Explanation

A. Pulmonary embolism: Pulmonary embolism presents with sudden onset of chest pain, tachycardia, hypotension, and restlessness, which aligns with the client's symptoms. It is a common postoperative complication due to immobility and potential hypercoagulability.
B. Pneumonia: Pneumonia typically develops more gradually and presents with fever, productive cough, and respiratory distress rather than sudden chest pain and hemodynamic instability. It is less likely in the immediate postoperative period.
C. Hemorrhage: Hemorrhage would also cause tachycardia and hypotension, but it would typically present with symptoms such as excessive bleeding, swelling at the surgical site, and pallor rather than chest pain.
D. Myocardial infarction: While myocardial infarction can cause chest pain, tachycardia, and hypotension, it is less likely in this scenario compared to a pulmonary embolism, given the timing and nature of the symptoms in the immediate postoperative period.

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A client is being transferred to the medical-surgical unit from the PACU after receiving general anesthesia for a procedure. Which of the following actions is the priority for the nurse when the client arrives on the unit?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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