Nokea
65-year-old Dominic is being transferred into the PACU from the OR. Once there, initial assessment will focus on:
- A. Airway, breathing, circulation, and wound site.
- B. Intake, output, and intravenous access.
- C. Abdominal sounds, oxygen setting, and level of consciousness.
- D. Pulse oximeter, pupil responses, and deep tendon reflexes.
Correct Answer: A
Rationale: The ABCs (airway, breathing, circulation) are the priority in postoperative assessments to ensure the patient's immediate physiological stability. The wound site is also assessed for signs of bleeding or infection.
You may also like to solve these questions
A client in an emergency department has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?
- A. Raise the foot of the bed to a 90° angle
- B. Remove the dressing to inspect the wound
- C. Prepare to insert a central line
- D. Administer oxygen via nasal cannula
Correct Answer: D
Rationale: The correct answer is D: Administer oxygen via nasal cannula. In a client with a sucking chest wound, the priority is to ensure adequate oxygenation due to potential respiratory compromise. Administering oxygen via nasal cannula will help improve oxygenation and support the client's respiratory function. This action takes precedence over other interventions as hypoxia can lead to further deterioration.
A: Raising the foot of the bed to a 90° angle is not indicated in this situation as it does not address the immediate need for oxygenation.
B: Removing the dressing to inspect the wound can worsen the condition by disrupting any seals in place to prevent air from entering the chest cavity.
C: Preparing to insert a central line is not the priority in this situation as the client's respiratory status needs to be stabilized first.
For care of a patient who has oral cancer, which task would be appropriate to delegate to the LPN/LVN?
- A. Assist the patient to brush and floss.
- B. Give antacids and sucralfate suspension as ordered.
- C. Recommend saliva substitutes.
- D. Explain when brushing and flossing are contraindicated.
Correct Answer: A
Rationale: Assisting with oral hygiene is within the scope of practice for LPNs/LVNs, while medication administration and patient education require higher-level training.
In assessing the healing of a client's wound during a home visit, which of the following is the best indicator of good healing?
- A. White patches.
- B. Green drainage.
- C. Reddened tissue.
- D. Eschar development.
Correct Answer: C
Rationale: Reddened tissue indicates healthy granulation tissue.
The patient asks when she should take bisphosphonate medications for treatment of osteoporosis. You tell her
- A. On a full stomach.
- B. Just before getting into bed.
- C. First thing in the morning on an empty stomach with a full glass of water, 30 to 60 minutes before eating, and without lying down.
- D. With an acidic liquid such as orange juice.
Correct Answer: C
Rationale: Bisphosphonates require specific administration guidelines to enhance absorption.
A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?
- A. Check the tubing connections for leaks.
- B. Check the suction control outlet on the wall.
- C. Clamp the chest tube.
- D. Continue to monitor the client's respiratory status.
Correct Answer: A
Rationale: The correct answer is A: Check the tubing connections for leaks.
1. Slow, steady bubbling in the suction control chamber indicates an air leak in the system.
2. Checking the tubing connections for leaks is the appropriate action to identify and fix the issue.
3. This helps maintain the integrity of the closed chest drainage system and prevent complications.
Other choices are incorrect:
B: Checking the suction control outlet on the wall is not necessary as the issue is likely within the tubing system.
C: Clamping the chest tube could lead to tension pneumothorax and is not recommended unless ordered by a physician.
D: Continuing to monitor the client's respiratory status does not address the underlying problem of the air leak.