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

Administer prescribed analgesic medication

Administer oxygen at 2 L/min.

Raise the head of the bed.

Encourage coughing and deep breathing

Answer and Explanation

The Correct Answer is C

A. Administering analgesics is not a priority in managing low oxygen saturation.

B. Administering oxygen is important but should follow positioning to improve oxygenation.

C. Raising the head of the bed improves lung expansion and is the priority intervention.

D. Coughing and deep breathing can follow after oxygenation is stabilized.

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Correct Answer is C

Explanation

A. A blood pressure of 120/84 mm Hg is within normal limits and does not require immediate intervention.

B. Hypoactive bowel sounds are a common side effect of sedation and not an immediate concern.

C. A respiratory rate of 9 breaths per minute indicates respiratory depression, which is a life-threatening side effect of Propofol. Immediate intervention is required to maintain oxygenation.

D. Urine output of 90 mL over 2 hours is adequate and does not indicate acute distress.

A. Assess the surgical dressing, noting presence and character of drainage. B. Assess urinary output and presence of bladder distention. C. Assess blood pressure and the estimated blood loss during surgery. D. Assess for airway patency and quality of respirations.

Correct Answer is D

Explanation

A. Checking the surgical dressing is important but not as urgent as ensuring respiratory function.

B. Assessing urinary output is necessary but secondary to airway patency.

C. Monitoring blood pressure and blood loss is important but less critical than respiratory status.

D. Airway patency is the highest priority in the immediate postoperative period to prevent respiratory failure.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is D

Explanation

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