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

Check the breathing status

Check the client's blood pressure.

Check the client's level of pain

Check the client's level of consciousness.

Answer and Explanation

The Correct Answer is A

A. Check the breathing status:

According to ABC (Airway, Breathing, Circulation) priorities, breathing is assessed first to ensure airway patency and adequate ventilation.

B. Check the client's blood pressure:

Circulation is assessed after ensuring the airway and breathing are adequate.

C. Check the client's level of pain:

Pain assessment is important, but it is secondary to vital physiologic stability (airway, breathing, circulation).

D. Check the client's level of consciousness:

Important in recovery from anesthesia, but not prioritized over breathing assessment.

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Correct Answer is D

Explanation

A. Metallic taste in mouth:

This is not a typical sign of oxygen toxicity. A metallic taste may be associated with certain medications or exposure to metals.

B. Facial flushing:

Not a characteristic symptom of oxygen toxicity. Facial flushing is more commonly linked to fever or certain medication reactions.

C. Periorbital edema:

Swelling around the eyes may suggest fluid overload or renal issues, not oxygen toxicity.

D. Muscle twitching:

Oxygen toxicity can affect the central nervous system, leading to signs such as muscle twitching, seizures, and vision changes.

A. Numbness B. Pallor C. Cool skin D. Edema

Correct Answer is D

Explanation

A. Numbness:

Not a common sign of thrombophlebitis. May indicate nerve compression, not vein inflammation.

B. Pallor:

Pallor suggests arterial issues, such as poor perfusion. Thrombophlebitis affects veins, typically not causing pallor.

C. Cool skin:

Cool skin is also associated with arterial insufficiency. In thrombophlebitis, the area may be warm and tender.

D. Edema:

Edema occurs due to impaired venous return and inflammation, which is typical in thrombophlebitis.

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

Nursing Test Bank

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