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.

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Correct Answer is D

Explanation

Choice A reason:

Serum amylase is an enzyme related to the pancreas and is not elevated due to myocardial infarction. It is typically measured to diagnose pancreatitis and other pancreatic disorders, not cardiac events.

Choice B reason:

Aspartate aminotransferase (AST) is an enzyme found in the liver and muscle tissue, including the heart. While AST can be elevated after a myocardial infarction, it is not as specific as troponin I for cardiac muscle damage. AST levels can increase due to various conditions, making it a less definitive marker for myocardial infarction.

Choice C reason:

Unconjugated bilirubin is related to liver function and hemolysis and is not associated with myocardial infarction. It measures liver function and red blood cell breakdown, not cardiac injury.

Choice D reason:

Troponin I is the most specific and sensitive marker for myocardial infarction. Elevated levels of troponin I indicate cardiac muscle damage and are used to diagnose and assess the severity of a myocardial infarction. It is the preferred biomarker for detecting heart injuries due to its high specificity for cardiac tissue.

A. Degenerative joint changes B. Decreased gastric secretions C. Decreased sense of smell D. Diminished cough reflex

Correct Answer is D

Explanation

Choice A reason:

Degenerative joint changes affect mobility and physical function but do not directly contribute to the risk of aspiration pneumonia. These changes are more related to musculoskeletal issues rather than respiratory function.

Choice B reason:

Decreased gastric secretions affect digestion but do not directly increase the risk of aspiration pneumonia. This condition primarily impacts nutrient absorption and digestion, not the respiratory system.

Choice C reason:

A decreased sense of smell is more related to sensory perception and does not directly increase the risk of aspiration pneumonia. While it can affect the enjoyment of food and appetite, it does not impact the swallowing reflex or respiratory function.

Choice D reason:

A diminished cough reflex is a significant age-related change that increases the risk of aspiration pneumonia. The cough reflex helps clear the airway of secretions and prevent foreign substances from entering the lungs. As this reflex diminishes with age, the risk of aspiration and subsequent pneumonia increases, making it a key factor in the development of the condition.

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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?

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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?