The following 4 questions pertain to this case study:
In PACU, many assessments and interventions are done simultaneously. However, the most critical, high-priority assessment is:
Operative site
Airway
Pulse
Skin integrity
The Correct Answer is B
Choice A reason:
Assessing the operative site is important to monitor for signs of bleeding, infection, or other complications. However, it is not the most critical, high-priority assessment immediately after surgery. While the condition of the surgical site can provide valuable information about the patient’s recovery and potential complications, it does not take precedence over ensuring the patient’s airway is clear and they are breathing adequately. The operative site can be assessed once the patient’s airway, breathing, and circulation are stable.
Choice B reason:
Airway assessment is the most critical, high-priority assessment in the PACU. Ensuring that the patient’s airway is clear and they are breathing properly is paramount because anesthesia can depress the central nervous system, leading to compromised airway patency and respiratory function. The primary goal in the immediate postoperative period is to ensure that the patient is ventilating adequately to prevent hypoxia and other respiratory complications. This involves checking for airway obstruction, monitoring respiratory rate, and ensuring that oxygen saturation levels are within normal ranges (typically 95-100% for healthy individuals). Any issues with the airway must be addressed immediately to prevent life-threatening complications.
Choice C reason:
Assessing the pulse is crucial for monitoring the patient’s cardiovascular status, including heart rate and rhythm. This can help detect arrhythmias, hypovolemia, or other cardiovascular issues that may arise postoperatively. However, while important, it is secondary to ensuring that the patient’s airway is clear and they are breathing adequately. The pulse can be assessed once the airway and breathing are confirmed to be stable. Normal pulse rates for adults typically range from 60 to 100 beats per minute.
Choice D reason:
Assessing skin integrity is important for identifying signs of pressure ulcers, infection, or other skin-related issues. However, this assessment is not the highest priority immediately after surgery. Ensuring the patient’s airway, breathing, and circulation are stable takes precedence. Skin integrity can be assessed once the patient is stable and other critical assessments have been completed. Maintaining skin integrity is essential for overall patient care, but it does not supersede the need to ensure the patient is breathing properly and has a clear airway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Choice A: Monitor for signs and symptoms of infection
Monitoring for signs and symptoms of infection is a fundamental strategy in infection prevention. Early detection of infections allows for timely intervention, which can prevent the spread of pathogens and reduce the severity of the infection. Common signs and symptoms include fever, redness, swelling, pain, and discharge. Regular monitoring helps healthcare providers identify infections early and take appropriate actions, such as isolating the patient or starting treatment.
Choice B: Provide all patients with bottled water
Providing all patients with bottled water is not a standard infection prevention strategy. While ensuring access to clean drinking water is important, it is not specifically aimed at preventing infections. In healthcare settings, tap water is usually safe to drink if it meets regulatory standards. Bottled water may be provided in certain situations, such as during an outbreak of waterborne pathogens, but it is not a routine infection prevention measure.
Choice C: Provide education on infection prevention
Providing education on infection prevention is crucial for both healthcare providers and patients. Education helps individuals understand how infections spread and what measures they can take to prevent them. This includes proper hand hygiene, respiratory etiquette, and the importance of vaccinations. Educating patients and staff can significantly reduce the incidence of healthcare-associated infections by promoting adherence to infection control practices.
Choice D: Request an antibiotic order for a febrile patient
Requesting an antibiotic order for a febrile patient is not an infection prevention strategy but rather a treatment approach. Antibiotics are used to treat bacterial infections, not to prevent them. Overuse of antibiotics can lead to antibiotic resistance, making it crucial to use them judiciously and only when necessary. Infection prevention focuses on measures to prevent the occurrence of infections rather than treating them once they occur.
Choice E: Create a clean, safe environment
Creating a clean, safe environment is essential for infection prevention in healthcare settings. This involves regular cleaning and disinfection of surfaces, proper waste disposal, and maintaining hygiene standards. A clean environment reduces the risk of healthcare-associated infections by minimizing the presence of pathogens. Effective cleaning protocols and environmental controls are critical components of infection prevention strategies.
Correct Answer is A
Explanation
Choice A: True
Chemotherapy drugs work by targeting rapidly dividing cells, a characteristic of cancer cells. However, they cannot selectively distinguish between cancer cells and normal cells that also divide rapidly, such as those in the bone marrow, digestive tract, and hair follicles. This lack of selectivity leads to the common side effects of chemotherapy, such as hair loss, nausea, and decreased blood cell counts. The inability to differentiate between normal and cancer cells is a significant limitation of traditional chemotherapy.
Choice B: False
This choice is incorrect. If chemotherapy drugs could selectively target only cancer cells, the treatment would have fewer side effects and be more effective. However, the non-selective nature of these drugs means they also damage normal, healthy cells that divide rapidly. This non-selectivity is why patients undergoing chemotherapy often experience a range of side effects, as the treatment impacts both cancerous and healthy cells.
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