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 A

Explanation

Choice A rationale:

Hemorrhoids are swollen veins in the anus and rectum that can cause pain, itching, and bleeding. Sitz baths are a common and effective treatment for hemorrhoids because they can help to:

Reduce inflammation and pain Promote healing

Relax the anal sphincter muscles Cleanse the anal area

Warm water helps to increase blood flow to the area, which can help to reduce swelling and inflammation. The water also helps to soothe and cleanse the irritated tissues.

Sitz baths are typically taken for 10-15 minutes at a time, several times a day. They can be taken in a bathtub or a special sitz bath basin that fits over a toilet seat.

Choice B rationale:

A fractured right arm would not benefit from a sitz bath. Sitz baths are specifically for treating the anal and rectal area.

Choice C rationale:

An abscessed tooth would not benefit from a sitz bath. Sitz baths are specifically for treating the anal and rectal area.

Choice D rationale:

Painful back muscle spasms would not benefit from a sitz bath. Sitz baths are specifically for treating the anal and rectal area.

A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

Correct Answer is A

Explanation

Choice A rationale:

Stage 1 pressure injury:

Non-blanchable erythema of intact skin: This means that when you press on the area, the redness does not disappear. It is persistent and remains even after pressure is relieved, unlike other types of skin redness that may blanch temporarily.

Intact skin: This is a crucial characteristic of Stage 1. The skin is not broken or open, differentiating it from more advanced stages.

Commonly over bony prominences: The malleolus, or ankle bone, is a bony prominence that is susceptible to pressure injuries due to its location and potential for prolonged pressure.

Explanation:

Non-blanchable erythema: The description of the redness as "non-blanchable" is the key indicator of a Stage 1 pressure injury. Blanchable erythema, which disappears when pressure is applied, can be due to other causes like inflammation or skin irritation, but non-blanchable erythema signals a deeper issue with the tissue.

Intact skin: The fact that the skin is intact rules out Stages 2, 3, and 4, which all involve some degree of skin breakdown.

Location on a bony prominence: The malleolus is a common site for pressure injuries because it's a bony area that often bears weight, especially in those with limited mobility or those confined to beds or chairs.

Additional Information:

Pressure injuries, also known as pressure ulcers or bed sores, are areas of damage to the skin and underlying tissue caused by prolonged pressure.

They are a common problem in healthcare settings, particularly among patients with limited mobility. Early identification and intervention are crucial to prevent progression to more severe stages.

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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

Which patient would most likely benefit from a sitz bath?

Correct Answer is A

Explanation

If a patient has a non-blanchable area of redness on the right malleolus, what stage of pressure injury should be recorded in the patient’s medical record?

Correct Answer is A

Explanation

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