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Which is the priority intervention for the nurse to perform in the post anesthesia care unit (PACU)?

Assess the surgical dressing, noting presence and character of drainage.

Assess urinary output and presence of bladder distention.

Assess blood pressure and the estimated blood loss during surgery.

Assess for airway patency and quality of respirations.

Answer and Explanation

The Correct Answer is D

A. Checking the surgical dressing is important but not as urgent as ensuring respiratory function.

B. Assessing urinary output is necessary but secondary to airway patency.

C. Monitoring blood pressure and blood loss is important but less critical than respiratory status.

D. Airway patency is the highest priority in the immediate postoperative period to prevent respiratory failure.

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Correct Answer is C

Explanation

A. Administering analgesics is not a priority in managing low oxygen saturation.

B. Administering oxygen is important but should follow positioning to improve oxygenation.

C. Raising the head of the bed improves lung expansion and is the priority intervention.

D. Coughing and deep breathing can follow after oxygenation is stabilized.

A. Administer insulin B. Place the client on oxygen C. Administer intravenous dantrolene D. Cover the client with a warm blanket E. Administer intravenous flumazenil F. Administer cold intravenous saline

Correct Answer is ["B","C","F"]

Explanation

A: Insulin is not indicated unless hyperkalemia develops as a complication of malignant hyperthermia.

B: Administering oxygen helps address hypoxemia caused by increased metabolic activity and muscle rigidity.

C: Dantrolene is the treatment of choice for malignant hyperthermia. It reduces muscle rigidity and hypermetabolism.

D: Warm blankets are contraindicated as they exacerbate hyperthermia.

E: Flumazenil is used to reverse benzodiazepines and is unrelated to malignant hyperthermia management.

F: Cooling measures, including cold IV saline, help reduce hyperthermia.

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Which is the priority intervention for the nurse to perform in the post anesthesia care unit (PACU)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has returned to the unit on a stretcher following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is caring for a client experiencing malignant hyperthermia. Which intervention(s) is/are appropriate for this client? [Select All That Apply]

Correct Answer is ["B","C","F"]

Explanation

The nurse is caring for a client in the immediate post-operative period. On assessment, the nurse notes the client's bowels are protruding from the abdominal incision. Which intervention(s) by the nurse are most appropriate at this time? (Select All That Apply]

A nurse is caring for several clients in the post-operative unit. Which client should the nurse see first?

A client is receiving diazepam prior to a procedure. Which side effect should the nurse be most concerned about?

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The nurse is providing preoperative teaching. The client states, "I'm so nervous about my surgery". What is the best response by the nurse?

A client asks the nurse why they cannot consume food or liquids before surgery. Which response is most appropriate?

A nurse is teaching a newly licensed nurse about anesthesia. The nurse should include that an epidural is an example of which of the following types of anesthesia?

A nurse is educating a client on patient-controlled analgesia (PCA) pump. Which statement made by the client is correct?