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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct answer. Renal dysfunction is a common concern in older adults and significantly affects the clearance of medications from the body. Impaired kidney function can lead to the accumulation of drugs, increasing the risk of toxicity.
Choice B reason: Pancreatic impairment affects the digestion and absorption of nutrients, but it is not the primary concern related to medication toxicity. The liver and kidneys are more directly involved in drug metabolism and excretion.
Choice C reason: Increased gastric motility is not typically associated with medication toxicity. Slowed gastric emptying is more common in the elderly and can affect drug absorption, but it is not a primary cause of toxicity.
Choice D reason: Increased blood volume is not usually a physiological change in older adults and is not related to medication toxicity. Instead, decreased blood volume and changes in body composition are more typical and can affect drug distribution and metabolism.
Correct Answer is A
Explanation
Choice A reason:
Repositioning the client at least every 2 hours is a standard intervention to prevent further pressure ulcers and promote healing of existing ones. This practice helps alleviate pressure on vulnerable areas, improving blood circulation and reducing the risk of tissue breakdown.
Choice B reason:
Cleaning the wound with hydrogen peroxide solution is not recommended for pressure ulcers as it can damage healthy tissue and delay wound healing. Alternative wound cleaning solutions that are less harsh should be used to promote a more conducive healing environment.
Choice C reason:
Massaging reddened areas with dressing changes is contraindicated as it can exacerbate tissue damage and increase the risk of further ulceration. Gentle handling and appropriate wound care are essential to prevent additional harm to the affected areas.
Choice D reason:
Applying a heat lamp twice a day is not a standard or recommended practice for treating pressure ulcers. Heat can increase the risk of burns and further tissue damage. Proper wound care, including maintaining a clean and moist wound environment, is more effective for healing.
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