A semiconscious client in the post anesthesia care unit (PACU) is experiencing dyspnea (difficulty breathing). Which action should the nurse perform first?

In the PACU the nurse’s first priority is airway (A in ABCs). Once the airway is patent, the nurse can suction if needed, insert or maintain an appropriate airway adjunct, and administer oxygen or escalate care.

Rationale for correct answer:

4. Reposition the client to keep the tongue forward: For a semiconscious patient the immediate priority is to open and maintain a patent airway (head-tilt–chin-lift or jaw-thrust as appropriate) so air can move. This maneuver is quick and noninvasive.

Rationale for incorrect answers:

1. Place a pillow under the client’s head: A pillow may flex the neck and worsen upper airway obstruction from the tongue falling back. It does not reliably open the airway.

2. Remove the oropharyngeal airway: Unless the airway is known to be causing obstruction or eliciting a gag/vomiting reflex, removing an airway when it is actually helping patency can make the problem worse.

3. Administer oxygen by mask: Important, but not first if the airway is obstructed. Oxygen will not relieve hypoxia if airway patency is not established.

Take home points:

• Always address airway patency first in a dyspneic, altered patient.
• Don’t remove airway adjuncts unless they are known to be causing gagging or obstruction.
• If dyspnea persists after positioning, proceed to suction, insert or adjust airway adjuncts, and give oxygen.

When advancing a postoperative patient from NPO to clear liquids, the nurse checks for signs the GI tract and protective reflexes have returned: no nausea/vomiting, presence of bowel sounds or passage of flatus, intact gag reflex, and stable vital signs.

Rationale for correct answer:

1. Does not complain of nausea or vomiting: Absence of nausea or vomiting reduces aspiration risk and indicates the patient is more likely to tolerate oral intake.

3. States passing flatus: Passing flatus is an objective sign of returning bowel motility (ileus resolving) and supports advancing diet to clear liquids.

Rationale for incorrect answers:

2. Pain level is maintained at a rating of 2-3 out of 10: Good pain control is desirable, but a moderate pain score alone doesn’t guarantee GI tract readiness or safe swallowing.

4. Ambulates with minimal assistance: Ambulation shows overall stability and helps GI motility, but it is not by itself a direct indicator that the GI tract can tolerate oral intake.

5. Expresses feeling “hungry”: Subjective and not sufficient. Hunger does not confirm bowel function or absence of aspiration risk and should not be the sole reason to advance diet.

Take home points:

• Advance to clear liquids when objective signs of GI function and tolerance are present.
• Subjective cues (feeling hungry) and general stability (ambulating) are helpful context but do not replace primary clinical indicators of GI readiness.