Which is the priority initial assessment for a patient who is admitted to the post anesthesia care unit (PACU) after surgery with general anesthesia?
Temperature
Heart rate
Respirations
Blood pressure
The Correct Answer is C
A. Temperature: While temperature monitoring is important, hypothermia is not the most immediate concern after general anesthesia.
B. Heart rate: Although heart rate should be monitored, it is not the first priority in assessing an anesthetized patient.
C. Respirations: Airway and breathing are the top priorities in the PACU. General anesthesia can depress respiratory function, increasing the risk of airway obstruction or hypoventilation. Ensuring adequate ventilation is the first step in assessment.
D. Blood pressure: Blood pressure is important but secondary to airway and breathing in the initial assessment.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Nonrebreather mask. A nonrebreather mask delivers high concentrations of oxygen but requires a tight seal around the face, which is not suitable for patients with facial trauma.
B. Face tent. A face tent is the best option for a patient with facial trauma as it provides high-flow oxygen without requiring direct contact with the face, preventing pressure on injured areas.
C. Nasal cannula. A nasal cannula provides low-flow oxygen and may be ineffective for a patient requiring high-flow therapy.
D. Venturi mask. A Venturi mask delivers precise oxygen concentrations but still requires a snug fit on the face, which may not be comfortable or feasible for a patient with facial trauma.
Correct Answer is C
Explanation
A. Allow the client time alone to self-reflect.: Suicidal clients should not be left alone. They require immediate assessment and intervention.
B. Reassure the client that everything is going to work out.: Offering false reassurance can invalidate the client’s feelings and may discourage further discussion of their distress.
C. Ask the client about the lethality of their plan.: The nurse should assess the specifics of the client’s plan to determine the level of risk. A detailed, lethal plan indicates a higher suicide risk and requires immediate intervention.
D. Encourage the client to focus on the positive aspects of life.: While positive reinforcement is helpful, it does not address the immediate risk of suicide. The nurse should prioritize risk assessment and safety.
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