An unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU) 15 minutes ago has an oxygen saturation of 89%. Which action should the nurse take first?
Increase the oxygen flowrate.
Elevate the patient's head on two pillows.
Suction the patient's mouth.
Perform the jaw-thrust maneuver.
The Correct Answer is A
A. The most appropriate first action would be to increase the oxygen flowrate to improve the patient's oxygen saturation levels. This intervention directly addresses the hypoxemia and can help prevent further complications related to low oxygen levels in the blood.
B. Elevating the patient's head can help improve ventilation and oxygenation. By raising the head, the patient's airway may become more patent, allowing for better airflow and oxygen exchange in the lungs. However, this should follow oxygenation.
C. Suctioning the patient's mouth aims to remove any secretions or obstructions that may be compromising the airway and contributing to the low oxygen saturation. However, this should follow oxygenation.
D. This maneuver can be helpful if the airway is obstructed by the tongue or soft tissues, potentially improving ventilation and oxygenation. However, this should follow oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Acute compartment syndrome occurs when increased pressure within a muscle compartment compromises circulation to the muscles and nerves within that compartment. Fractures, especially those accompanied by significant soft tissue injury or bleeding, can lead to compartment syndrome.
A Osteomyelitis is an infection of the bone that can occur as a complication of fractures, particularly if the fracture is open (the bone breaks through the skin). This occurs in the later courses of an infection.
C Fat embolism syndrome occurs when fat globules from fractured bones enter the bloodstream and become lodged in small blood vessels in organs such as the lungs, brain, and skin. Increasing edema is not an early sign of fat embolism.
D Pulmonary embolism (PE) is a serious condition where a blood clot travels to the lungs and blocks blood flow. While fractures, especially long bone fractures, can increase the risk of developing blood clots, increasing edema in the fractured limb is not typically an early sign of pulmonary embolism.
Correct Answer is B
Explanation
B. Assessing the client's pain level is crucial, especially before physical therapy, as pain can affect participation and compliance with therapy. If the client is experiencing pain, appropriate pain management measures should be implemented before PT to optimize participation and comfort.
A. The nurse should educate the client on proper body mechanics and positions to avoid during physical therapy to promote safe movement and prevent complications. However, this is not a priority.
C. While morning care is important for maintaining hygiene and comfort, it may not be the priority at this specific time, especially if the client is scheduled for physical therapy soon.
D. Encouraging full weight bearing immediately postoperative may not be appropriate, as the surgical site needs time to heal and regain strength.
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