The post-anesthesia care unit nurse receives a patient from the operating room. Which assessment will the nurse perform first?
Check intravenous lines for patency or redness.
Check nasogastric tube and presence of bowel sounds.
Check airway, lung sounds, and pulse oximetry.
Check Foley catheter and surgical fluid intake.
The Correct Answer is C
Choice A rationale:
While checking intravenous lines for patency and redness is important, it's not the most immediate priority in the post- anesthesia care unit (PACU). Ensuring airway patency and adequate oxygenation takes precedence over IV assessment. Issues with IV lines can usually be addressed quickly if they arise, whereas compromised airway or breathing can rapidly lead to life- threatening complications.
Choice B rationale:
Assessment of nasogastric tubes and bowel sounds is also important, but it's not as urgent as checking the airway and breathing. Bowel sounds may be absent immediately after surgery due to anesthesia and bowel manipulation, and their presence or absence doesn't necessarily indicate an immediate problem. Similarly, nasogastric tubes can be checked and adjusted as needed after ensuring the patient's airway and breathing are stable.
Choice D rationale:
Checking the Foley catheter and surgical fluid intake is essential for monitoring fluid balance and renal function, but it's not a priority over assessing airway, breathing, and circulation (ABCs). Fluid status can be assessed and managed after ensuring the patient's respiratory and circulatory systems are functioning adequately.
Choice C rationale:
Checking the airway, lung sounds, and pulse oximetry is the most critical assessment in the PACU because it ensures that the patient is breathing effectively and has adequate oxygen saturation. This assessment addresses the primary ABCs of patient care:
Airway: The nurse will assess for any obstructions or potential for obstruction, such as swelling, secretions, or the tongue blocking the airway. They will also ensure proper positioning of the head and neck to maintain airway patency.
Breathing: The nurse will listen to lung sounds to evaluate air entry and identify any signs of respiratory distress, such as wheezing, crackles, or decreased breath sounds. They will also monitor respiratory rate and effort.
Circulation: Pulse oximetry measures oxygen saturation in the blood, providing a quick and non-invasive assessment of oxygenation status. It's essential to ensure adequate oxygen delivery to tissues and organs.
By prioritizing the assessment of airway, lung sounds, and pulse oximetry, the nurse can quickly identify and intervene in any respiratory or oxygenation issues, preventing potentially life-threatening complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Intravenous (IV) administration delivers medication directly into the bloodstream. This route is not appropriate for insulin because it would result in a rapid and potentially dangerous drop in blood glucose levels. Insulin needs to be absorbed more slowly to mimic the natural release of insulin from the pancreas.
IV administration also requires sterile technique and specialized equipment, making it more complex and time-consuming than subcutaneous injection.
Additionally, there is a higher risk of infection and other complications with IV administration.
Choice B rationale:
The vastus lateralis is a muscle in the thigh that is commonly used for intramuscular (IM) injections. However, IM injections are not typically used for insulin administration because they can be more painful and have a slower absorption rate than subcutaneous injections.
IM injections also carry a higher risk of hitting a blood vessel, which could lead to erratic absorption of insulin.
Choice D rationale:
The deltoid is a muscle in the upper arm that can be used for subcutaneous injections. However, the abdomen is generally the preferred site for insulin injection because it has a greater amount of subcutaneous fat, which helps to slow the absorption of insulin and provide a more consistent effect.
The abdomen is also a more convenient site for self-injection, as it is easily accessible.
Choice C rationale:
The fatty tissue of the abdomen is the ideal site for subcutaneous insulin injection because it provides slow and consistent absorption of insulin.
The abdomen has a rich blood supply, which helps to distribute the insulin throughout the body.
The subcutaneous tissue in the abdomen is relatively thin, which makes it easy to inject insulin without causing pain or discomfort.
The abdomen is also a large area, which allows for multiple injection sites to be used and rotated to prevent lipohypertrophy (thickening of the subcutaneous tissue).
Correct Answer is ["A","B","C","F","G"]
Explanation
Rationale for each choice:
Choice A: Hypovolemia
Impaired perfusion: Hypovolemia, or a decrease in circulating blood volume, leads to reduced blood flow to the wound site. This means that less oxygen and nutrients are delivered to the tissues, which are essential for healing processes like cell growth and collagen synthesis.
Impaired oxygen delivery: Oxygen is crucial for white blood cells to fight infection and for fibroblasts to create new tissue. Hypovolemia can significantly hinder wound healing by reducing oxygen availability at the wound site.
Delayed inflammatory response: The inflammatory phase of wound healing relies on adequate blood flow to deliver immune cells and initiate tissue repair. Hypovolemia can delay this response, leading to prolonged inflammation and delayed healing.
Decreased fibroblast activity: Fibroblasts, the cells responsible for collagen production, require oxygen and nutrients to function effectively. Hypovolemia can impair fibroblast activity, leading to reduced collagen synthesis and delayed wound closure.
Choice B: Poorly controlled blood glucose levels
Impaired immune function: High blood glucose levels impair the function of white blood cells, making the body more susceptible to infections. Infections at the wound site can significantly delay healing.
Impaired collagen synthesis: Hyperglycemia can also impair collagen synthesis, which is essential for wound strength and closure.
Vascular damage: Chronically high blood glucose levels can damage blood vessels, leading to impaired blood flow and oxygen delivery to the wound site, further hindering healing.
Choice C: Protein deficiency
Impaired collagen synthesis: Protein is a crucial building block for collagen, the main structural protein in connective tissue. A lack of protein can lead to reduced collagen production, resulting in delayed wound healing and weaker scar tissue.
Impaired immune function: Protein is also essential for immune cell function. A deficiency can impair the body's ability to fight infections, increasing the risk of wound complications.
Choice D: Adequate hydration
Incorrect: Staying well-hydrated supports the body’s healing process by ensuring proper blood flow and nutrient transport, thus it does not impede wound healing.
Choice E: Routine ambulation
Incorrect: Early ambulation after surgery promotes healing by improving circulation and reducing the risk of complications like blood clots, making it beneficial rather than harmful.
Choice F: Steroid therapy
Immunosuppressive effects: Steroids suppress the immune system, making the body less able to fight infections and hindering the inflammatory phase of wound healing.
Decreased collagen synthesis: Steroids can also decrease collagen synthesis, leading to weaker wound tissue and delayed closure.
Choice G: Obesity
Impaired blood flow: Excess adipose tissue can compress blood vessels, reducing blood flow to the wound site and impairing oxygen and nutrient delivery.
Increased inflammation: Adipose tissue produces inflammatory cytokines, which can prolong the inflammatory phase of wound healing and delay tissue repair.
Higher risk of infection: The folds of skin in obese individuals can create moist environments that are more prone to bacterial growth and infection.
Choice H: Vitamin C supplementation
Incorrect: Vitamin C plays a key role in collagen formation and tissue repair, so it supports rather than hinders wound healing.
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