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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

D. Difficulty or inability to abduct (raise out to the side) the arm at the shoulder is a classic finding in rotator cuff injuries, particularly in cases of significant tears or severe inflammation. This limitation in shoulder movement can be due to pain, weakness, or mechanical impingement caused by the injured rotator cuff.

A. The drop arm test is a physical examination maneuver used to assess for rotator cuff tears. In a negative drop arm test, the patient is able to slowly lower their arm from an abducted position (out to the side) to their side without significant pain or weakness. A negative test suggests that there may not be a complete tear of the rotator cuff.

B. Alteration in the contour of the shoulder joint could indicate various shoulder pathologies, including rotator cuff injuries. However, it is a nonspecific finding and can occur with other shoulder conditions as well.

C. Tinel's sign is a test used to assess for nerve compression or irritation. While it can be positive in conditions such as carpal tunnel syndrome, it is not typically associated with rotator cuff injuries.

A. Tympanic temperature 99.2° F (37.3° C) B. Fine crackles audible at both lung bases C. 200 mL sanguineous fluid in the wound drain D. Redness and swelling along the suture line

Correct Answer is C

Explanation

C. Excessive sanguineous fluid in the drain could indicate active bleeding or a hematoma formation, which are significant concerns after surgery. It should be reported to allow for appropriate intervention to prevent shock

A. A slight elevation in temperature can be expected in the immediate postoperative period due to the body's response to surgery (surgical stress response).

B. Fine crackles indicate the presence of fluid in the lungs, which could suggest complications such as pulmonary edema or atelectasis. While this finding warrants monitoring and intervention, it may not be the most critical issue to report to the surgeon in this context.

D. Redness and swelling along the suture line can indicate inflammation or infection at the surgical site. This is a normal response of the tissues to trauma such as surgery.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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