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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

Loosening the tape gently by pressing the skin away from it is an important step in changing a burn dressing. However, it is not the first intervention that should be performed. This is because removing the tape can be painful, and it is important to ensure that the patient is adequately pain-free before proceeding.

Choice B rationale:

Observing the wound bed for the presence of granulation tissue is also an important part of burn care. Granulation tissue is a sign of healing, and its presence indicates that the wound is progressing as expected. However, this assessment is not the first priority when changing a dressing. Pain management should always be addressed first.

Choice D rationale:

Gently irrigating the wound using sterile normal saline is another important step in burn care. Irrigation helps to cleanse the wound and remove any debris or dead tissue. However, it should not be performed until the patient's pain has been adequately controlled.

Choice C rationale:

Administering pain medication 30 minutes beforehand is the most important first intervention when changing a painful burn dressing. This allows time for the medication to take effect and ensure that the patient is comfortable before the dressing change begins. Pain management is crucial in burn care, as it can help to reduce anxiety, promote healing, and improve patient outcomes.

A. The patient’s skin will be free of redness or breakdown when surgery is complete. B. The patient’s privacy and dignity will be maintained throughout the procedure. C. The patient’s bony prominences will be padded with pressure-reducing cushions. D. The patient’s skin will be assessed prior to surgery to identify areas at risk.

Correct Answer is A

Explanation

Choice A rationale:

Directly addresses the primary goal of preventing perioperative positioning injury: The absence of redness or breakdown in the skin is the most definitive indicator that the patient has not sustained any skin or tissue damage as a result of prolonged immobilization during surgery.

Focuses on the patient outcome, not just interventions: While interventions such as padding bony prominences and assessing skin prior to surgery are important, they are means to achieve the ultimate goal of preventing skin injury. This outcome statement directly measures the success of those interventions.

Aligns with best practices for pressure injury prevention: The National Pressure Injury Advisory Panel (NPIAP) and other expert organizations emphasize the importance of setting goals that focus on maintaining skin integrity and preventing injury.

Choice B rationale:

Addresses a crucial aspect of patient care, but not directly related to positioning injury: Maintaining privacy and dignity is essential for all patients, but it does not specifically address the risk of skin breakdown from prolonged immobilization.

Not a measurable outcome for positioning injury: It is difficult to objectively assess whether a patient's privacy and dignity have been maintained, making it less suitable as an outcome statement for this particular diagnosis.

Choice C rationale:

Describes an important intervention, but not a patient outcome: Padding bony prominences is a key strategy to reduce pressure and prevent skin injury. However, it is an action taken by the nurse, not a measurable outcome that reflects the patient's status.

Does not guarantee prevention of injury: Even with appropriate padding, patients can still develop pressure injuries if other risk factors are present or if repositioning is not performed adequately.

Choice D rationale:

Represents an essential assessment step, but not a final outcome: Assessing the skin prior to surgery is important for identifying areas that are at increased risk of breakdown. However, it is a preliminary step in the prevention process, not the ultimate goal.

Does not ensure prevention of injury: Identifying at-risk areas is helpful for targeting interventions, but it does not guarantee that skin breakdown will not occur.

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The post-anesthesia care unit nurse receives a patient from the operating room. Which assessment will the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is the first intervention of the nurse for changing the dressing to a painful burn?

Correct Answer is C

Explanation

A nurse is caring for a patient who will be undergoing a surgical procedure that will take 7 to 8 hours to complete.What is the appropriate outcome for the diagnosis of perioperative positioning injury related to prolonged immobilization?

Correct Answer is A

Explanation

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