A nurse is caring for a client who arrived at the post anesthesia care unit (PACU) following a right knee arthroscopy. The client is not yet responding to verbal stimuli. Which of the following actions should the nurse perform first?

Place the patient in a lateral position.

Apply a warm blanket.

Compare and contrast peripheral pulses.

Assess their dressings.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Placing the patient in a lateral position (recovery position) is critical to maintain an open airway and prevent aspiration, especially in a client who is not responding to verbal stimuli. This position helps ensure that the airway remains clear and reduces the risk of aspiration if the client vomits.

Choice B reason:

Applying a warm blanket is important for maintaining the client’s body temperature but is not the immediate priority when the client is unresponsive. Ensuring airway patency takes precedence.

Choice C reason:

Comparing and contrasting peripheral pulses is part of the assessment process but is not the first priority. Ensuring the client's airway and breathing are secure is more urgent.

Choice D reason:

Assessing dressings is necessary to monitor for bleeding or other complications but is not as immediate as ensuring the client’s airway is clear and protected.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason:

A diuretic medication is generally used to remove excess fluid from the body and treat conditions such as hypertension and heart failure. While it can be part of the management plan for atrial fibrillation if there is fluid overload, it is not specifically used to prevent thromboembolic events like TIA, which are a major concern in atrial fibrillation patients.

Choice B reason:

An oral anticoagulant medication is the most appropriate choice for a patient with atrial fibrillation who has experienced a TIA. Anticoagulants, such as warfarin or newer direct oral anticoagulants (DOACs), are used to prevent blood clots from forming and reduce the risk of stroke and other thromboembolic events. This choice directly addresses the primary goal of reducing the risk of future TIAs or strokes in patients with atrial fibrillation.

Choice C reason:

A beta blocker medication can be useful in managing atrial fibrillation by controlling the heart rate and reducing the risk of symptomatic episodes. However, beta blockers do not address the risk of thromboembolism, which is critical in the context of a patient with a history of TIA. Thus, while beneficial for rate control, they do not serve the primary purpose of preventing strokes in this scenario.

Choice D reason:

An antihyperuricemic medication is used to lower uric acid levels and treat conditions like gout. It is not relevant to the management of atrial fibrillation or the prevention of thromboembolic events. Including this option does not align with the clinical needs of a patient with atrial fibrillation and a history of TIA.

A. Reposition the client every 2 hours. B. Massage the skin over the client's bony prominences. C. Position the client in high Fowler's. D. Apply cornstarch to keep sensitive skin areas dry.

Correct Answer is A

Explanation

Choice A reason:

Repositioning the client every 2 hours is a standard preventive measure to reduce the risk of pressure ulcers. Frequent repositioning helps alleviate pressure on vulnerable areas, improving circulation and preventing skin breakdown. This intervention is widely recommended to maintain skin integrity in at-risk clients.

Choice B reason:

Massaging the skin over bony prominences can cause tissue damage and increase the risk of pressure ulcers. Instead of promoting circulation, it can exacerbate skin breakdown and should be avoided as a preventive measure.

Choice C reason:

Positioning the client in high Fowler's is not specifically related to preventing pressure ulcers. High Fowler's position can help with respiratory issues but does not address pressure redistribution needed to prevent skin breakdown in vulnerable areas.

Choice D reason:

Applying cornstarch to keep sensitive skin areas dry is not an evidence-based intervention for pressure ulcer prevention. Cornstarch can create friction and irritation, potentially worsening skin integrity rather than preserving it.

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 caring for a client who arrived at the post anesthesia care unit (PACU) following a right knee arthroscopy. The client is not yet responding to verbal stimuli. Which of the following actions should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is diagnosed with atrial fibrillation and has experienced a transient ischemic attack (TI

Correct Answer is B

Explanation

A nurse is planning care for an older adult client at risk for developing pressure ulcers. Which intervention is appropriate to maintain skin integrity?

Correct Answer is A

Explanation

A client taking a newly prescribed monoamine oxidase inhibitor (MAOI) is receiving education on foods that contain tyramine. Which of the following foods should be excluded from the client's diet? (Select all that apply.)

A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure, which nursing action should the nurse complete first?

A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect?

A nurse is teaching a client who has a new prescription for ferrous sulfate. Which of the following information should the nurse include in the teaching?

A nurse is preparing to administer a medication to a client who states, "That looks different from the pill I usually take." Which is the best response by the nurse?

A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which action should the nurse take first?

A health care provider has written an order for digoxin for the patient, but the nurse cannot read whether the order is for 0.25 mg or 0.125 mg. What action would be the best to prevent a medication error?

The nurse is preparing to discharge a client newly prescribed a progestin-only pill (POP) for contraceptive prevention. Which contraindication associated with POP should the nurse alert the healthcare provider?