A nurse is admitting a client to the post-anesthesia care unit. Which of the following actions should the nurse take first?

Check the client’s airway.

Check the client’s level of consciousness.

Check the client’s blood pressure.

Check the client’s level of pain.

Answer and Explanation

The Correct Answer is A

Choice A reason: Checking the airway is the priority in post-anesthesia care, as anesthesia can cause respiratory depression or obstruction due to reduced pharyngeal muscle tone. Ensuring airway patency prevents hypoxia, maintaining oxygen delivery to vital organs, critical for patient safety and stabilization post-surgery.

Choice B reason: Level of consciousness is assessed after ensuring airway and breathing, as anesthesia (e.g., propofol) depresses the central nervous system. While important for neurological status, it is secondary to airway patency, as hypoxia from an obstructed airway poses an immediate life-threatening risk in the post-anesthesia period.

Choice C reason: Blood pressure monitoring is crucial to assess hemodynamic stability post-anesthesia, as hypotension may result from anesthetic agents or blood loss. However, airway obstruction causes hypoxia faster than cardiovascular instability, making airway assessment the first priority to ensure oxygenation before addressing circulatory parameters.

Choice D reason: Pain assessment is important for patient comfort and recovery but is not the first priority. Uncontrolled pain may increase sympathetic activity, affecting heart rate, but airway compromise causes rapid hypoxia, posing a greater immediate threat, requiring airway evaluation before addressing pain levels.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Inhaling through the mouth is not the primary focus of coughing and deep breathing exercises, which emphasize deep inhalation (often through the nose) to expand alveoli. Mouth breathing may reduce efficiency, as nasal breathing filters air and optimizes lung expansion, making this an incorrect instruction for preoperative teaching.

Choice B reason: Holding the breath for 5 seconds after a deep inhalation sustains lung expansion, promoting alveolar gas exchange and preventing atelectasis. This technique strengthens respiratory muscles and clears secretions, critical for postoperative recovery. It is a key component of coughing and deep breathing exercises to maintain pulmonary health.

Choice C reason: Exhaling through the nose is not typically emphasized in coughing and deep breathing exercises. Effective coughing requires forceful exhalation through the mouth to expel secretions and clear airways. Nasal exhalation is less effective for this purpose, making this an incorrect instruction for preoperative pulmonary care.

Choice D reason: Repeating coughing exercises every 2 hours is a general guideline, but the focus is on frequency while awake (e.g., every 1-2 hours). The exact timing depends on the client’s condition, and the technique’s effectiveness relies more on proper breathing and coughing methods, making this less critical than breath-holding.

A. Client’s response to interventions implemented B. Interventions implemented in response to a client’s blood pressure C. The frequency in which a blood pressure is taken D. A client’s position when the blood pressure was obtained E. The site where the blood pressure was obtained

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

Explanation

Choice A reason: Documenting the client’s response to interventions, such as medication or positional changes, is critical for evaluating treatment efficacy and guiding care. This includes noting changes in blood pressure or symptoms post-intervention, ensuring continuity of care. Accurate records support clinical decision-making and reflect the physiological impact of interventions on the cardiovascular system.

Choice B reason: Interventions implemented, such as administering antihypertensives or fluids, must be documented to track actions taken in response to blood pressure readings. This ensures a clear record of care provided, facilitating communication among healthcare providers and enabling evaluation of treatment effectiveness in managing the client’s cardiovascular status.

Choice C reason: The frequency of blood pressure measurements is essential to document, as it indicates monitoring intensity based on the client’s condition. For example, unstable patients may require frequent checks. This information ensures consistency in care, tracks trends in cardiovascular status, and supports timely interventions for abnormal readings.

Choice D reason: The client’s position (e.g., sitting, lying, standing) during blood pressure measurement affects readings due to gravitational effects on blood flow. Documenting position ensures accurate interpretation of results, as orthostatic changes can indicate hypovolemia or autonomic dysfunction. This detail is critical for assessing cardiovascular stability and guiding treatment plans.

Choice E reason: The site of blood pressure measurement (e.g., arm, wrist, thigh) must be documented, as different sites can yield varying readings due to arterial size and proximity to the heart. Specifying the site ensures consistency in serial measurements and accurate interpretation of cardiovascular status, supporting reliable clinical decision-making.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is admitting a client to the post-anesthesia care unit. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing preoperative teaching for a client about coughing and deep breathing. Which of the following statements should the nurse make?

Correct Answer is B

Explanation

A nurse is documenting a client’s blood pressure. Which of the following should the nurse include in the documentation? (Select all that apply)

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

Explanation

A nurse is teaching a client who reports insomnia. Which of the following statements should the nurse make?

A nurse is planning to learn about a culture by observing the cultural practices from the outside. The nurse is planning to obtain which of the following types of information?

A nurse is caring for a client who has a terminal diagnosis and states, "I am ready to update my will." The nurse should identify that the client is experiencing which of the following Kubler-Ross stages of grief?

A nurse is teaching a female client who is to start taking atorvastatin. Which of the following baseline examinations should the nurse include?

A nurse is assessing a client who has obstructive sleep apnea (OSA). Which of the following findings should the nurse expect?

A nurse in the emergency department is caring for a client who took three nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now experiences a headache. Which of the following statements should the nurse make?

A nurse is admitting a client to the post-anesthesia care unit. Which of the following actions should the nurse take first?

A nurse is caring for an adolescent who is experiencing indications of depression. Which of the following findings should the nurse expect? (Select all that apply)