A nurse is assisting with the care of a client in a PACU.

Which of the following actions should the nurse take during the management of oxygenation for this client?

Select all that apply.

Examine the client's nail beds.

Place the client in the supine position.

Encourage client to perform deep breathing exercises.

Add a humidifier to the oxygen device.

Prepare to administer oxygen via Venturi face mask

Answer and Explanation

Correct Answer : A,C,D

Oxygenation management in the postanesthesia care unit involves maintaining adequate ventilation and oxygen delivery following sedative or anesthetic procedures such as a Colonoscopy performed under sedation. Post-sedation clients are at risk for hypoventilation, airway obstruction, and mild hypoxemia due to residual anesthetic effects. Nursing care focuses on optimizing oxygen delivery, promoting lung expansion, and continuously assessing for early signs of respiratory compromise. Interventions should support airway patency and improve oxygen exchange while maintaining patient safety.

Rationale:
A. Examining the client’s nail beds helps assess peripheral oxygenation status by evaluating capillary refill and signs of cyanosis. Delayed capillary refill or bluish discoloration may indicate inadequate oxygen delivery to tissues. In post-sedation clients, peripheral perfusion assessment provides an additional indicator of hypoxemia beyond pulse oximetry readings.

B. Placing the client in a supine position is inappropriate because it can worsen ventilation and increase the risk of airway obstruction, especially after sedation. Supine positioning promotes posterior pharyngeal collapse and reduces lung expansion. A semi-Fowler’s position is preferred to enhance diaphragmatic excursion and improve oxygenation.

C. Encouraging deep breathing exercises promotes alveolar expansion and prevents atelectasis, which is a common complication after sedation and immobility. Deep breathing increases tidal volume and improves oxygen diffusion across alveolar-capillary membranes. It also assists in mobilizing secretions, thereby improving overall ventilation and oxygenation status.

D. Adding a humidifier to the oxygen device is appropriate because dry oxygen can irritate the mucous membranes and thicken respiratory secretions. Humidification helps maintain airway moisture, improves secretion clearance, and enhances patient comfort during oxygen therapy. This is particularly beneficial when oxygen is delivered at higher flow rates.

E. Preparing to administer oxygen via a Venturi face mask is not indicated at this time because the client’s oxygen saturation remains near target levels with nasal cannula adjustments. A Venturi mask is typically used when precise oxygen delivery is required in moderate to severe hypoxemia or COPD management. The current prescription allows titration via nasal cannula up to 5 L/min, making escalation unnecessary unless deterioration occurs.

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Correct Answer is B

Explanation

Bowel sounds are produced by the movement of air and fluid through the intestines and are assessed during abdominal examination to evaluate gastrointestinal motility. They can vary in frequency, intensity, and pitch depending on underlying intestinal activity. Hyperactive bowel sounds indicate increased peristalsis, often associated with conditions that accelerate intestinal movement such as diarrhea or early obstruction. Understanding the characteristics of bowel sounds helps differentiate between normal and abnormal gastrointestinal function.

Rationale:
A. Paralytic ileus is associated with absent or significantly reduced bowel sounds due to decreased or halted intestinal motility. It represents a state of bowel inactivity rather than increased activity, so it is not associated with hyperactive sounds.

B. Hyperactive bowel sounds are correctly described as high-pitched and more frequent than normal. These sounds result from increased intestinal peristalsis and are often heard in conditions such as gastroenteritis, laxative use, or early bowel obstruction in which the intestines attempt to push contents forward more rapidly.

C. Decreased motility is associated with hypoactive or absent bowel sounds, not hyperactive sounds. Conditions such as postoperative states, peritonitis, or paralytic ileus typically reduce intestinal activity rather than increase it.

D. Soft sounds occurring at a rate of 1/min describe hypoactive bowel sounds, not hyperactive ones. This pattern suggests slowed intestinal activity, which may be normal during sleep or indicative of reduced gastrointestinal function.

A. WBC count 8,000/mm3 (5,000 to 10,000 mm3) B. Edema to the area around the incision site C. Serous drainage in the closed suction collection device D. Urine output is 40 mL/hr

Correct Answer is B

Explanation

Postoperative clients require close monitoring for early signs of complications such as infection, bleeding, and impaired wound healing. Surgical site infection typically develops within a few days after surgery and is associated with localized inflammatory changes and systemic responses. Nurses assess wound appearance, drainage characteristics, vital signs, and laboratory values to detect deviations from normal healing. Early identification of infection allows for timely intervention and prevents progression to systemic sepsis.

Rationale:
A. A WBC count of 8,000/mm³ is within the normal range and does not indicate infection. Although elevated white blood cells can suggest infection, this value does not reflect an inflammatory or infectious process. Normal laboratory findings alone do not support postoperative infection.

B. Edema around the incision site may indicate localized inflammation associated with a developing surgical site infection. In Postoperative wound infection, swelling may be accompanied by warmth, redness, pain, and possible purulent drainage. While mild edema can occur normally after surgery, increasing or persistent swelling beyond expected healing patterns suggests infection and requires further assessment.

C. Serous drainage in a closed suction device is expected in the early postoperative period and represents normal healing. Serous fluid is clear or pale yellow and indicates plasma leakage without infection. Infected wounds typically produce purulent, foul-smelling, or cloudy drainage rather than serous fluid.

D. A urine output of 40 mL/hr is within the normal expected range for an adult (generally ≥30 mL/hr). This finding reflects adequate renal perfusion and does not indicate infection. It is unrelated to surgical site infection unless systemic complications develop.

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A nurse is assisting with the care of a client in a PACU. Which of the following actions should the nurse take during the management of oxygenation for this client? Select all that apply.

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A nurse is assisting with the care of a client in a PACU.

Which of the following actions should the nurse take during the management of oxygenation for this client?

Select all that apply.