The circulating nurse notes that the anesthetized patient has tensed muscles and irregular respirations. The nurse is aware that the patient has reached stage:

Ill and the patient has depressed reflexes.

IV and the patient will not depend on the anesthesia machine of oxygenations.

Il and the surgical environment should be kept quiet.

and the patient's hearing is amplified.

Answer and Explanation

The Correct Answer is C

A. Stage III and the patient has depressed reflexes. Stage III of anesthesia is the surgical stage, where the patient is under deep anesthesia, and reflexes are typically depressed. However, tensed muscles and irregular respirations may indicate that the patient is still in an earlier stage of anesthesia (stage II).

B. Stage IV and the patient will not depend on the anesthesia machine for oxygenation. Stage IV is the deepest level of anesthesia, where respiratory and cardiovascular functions are severely depressed. It does not match the description of tensed muscles and irregular respirations, which are more characteristic of an earlier stage (stage II).

C. Stage II and the surgical environment should be kept quiet. Stage II of anesthesia is the excitement stage, where patients may exhibit tensed muscles, irregular respirations, and uncoordinated movements. The surgical environment should be kept quiet to minimize stimuli that could cause agitation or further excitement in this stage.

D. Stage I and the patient's hearing is amplified. Stage I is the stage of anesthesia where the patient is still conscious and responsive to stimuli. The description of tensed muscles and irregular respirations does not match this stage. Additionally, the patient’s hearing would not be amplified in stage I, but rather in stage II or as they begin to emerge from anesthesia.

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Correct Answer is ["B","C","D"]

Explanation

A. To achieve fast-acting pain relief, administer analgesics PO. Oral (PO) medications may not provide rapid pain relief, particularly postoperatively. IV or other forms of analgesia are preferred for fast-acting relief.

B. Consider the client's individual expression of pain. Pain is subjective, and the nurse should consider each patient’s unique expression of pain to provide appropriate pain management.

C. Expect the client to express his pain both verbally and nonverbally. Patients may express pain verbally or nonverbally, such as through facial expressions or body movements. The nurse must be attentive to both forms of expression.

D. Use a scale from 0 to 10 to monitor the severity of the client's pain. The 0 to 10 pain scale is a common and effective tool for assessing the severity of a patient's pain, allowing for appropriate intervention.

E. Administer opioids with caution because they will eventually lead to addiction. While opioids should be used cautiously, the focus should be on appropriate and safe pain management. Addiction is not an immediate concern for postoperative patients who require short-term use.

A. head of bed at 45 degrees with head and neck midline. B. side lying. C. supine. D. head of bed at 30 degrees with head and neck midline.

Correct Answer is B

Explanation

A. Head of bed at 45 degrees with head and neck midline. Although the head of the bed at 45 degrees can be appropriate for some patients, it is not the best position to maintain a patent airway for a drowsy postoperative patient. This position can lead to airway obstruction, especially if the patient is drowsy.

B. Side lying. The side-lying position is the best choice for a patient who is drowsy and requires verbal stimulation to remain aroused. This position prevents aspiration and ensures that the airway remains patent by allowing any secretions or fluids to drain from the mouth. It is especially useful in the postoperative period to prevent airway obstruction.

C. Supine. The supine position is not ideal for a drowsy postoperative patient, as it can increase the risk of airway obstruction. The tongue may fall back and obstruct the airway, particularly if the patient is drowsy.

D. Head of bed at 30 degrees with head and neck midline. Although elevating the head of the bed at 30 degrees is common, it is not the best choice for a drowsy patient at risk for airway obstruction. Side-lying would be more effective in preventing aspiration and maintaining the airway.

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The circulating nurse notes that the anesthetized patient has tensed muscles and irregular respirations. The nurse is aware that the patient has reached stage:

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative. When helping to manage the client's pain, which of the following principles should the nurse apply? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

A patient who has returned to the surgical nursing unit from the post-anesthesia care unit (PACU) is drowsy and requires verbal stimulation to remain aroused. The best position to maintain an airway for this patient is:

Correct Answer is B

Explanation

A nurse is caring for a client who is postoperative and has a prescription for a clear liquid diet. The nurse enters the client's room to find he has just received a dietary tray. Which of the following items on the tray should the nurse remove?

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