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The nurse evaluates that the interventions for the nursing diagnosis of ineffective airway clearance in a postoperative patient have been successful when which of the following goals has been met?
- A. Patient drinks 2-3 L of fluid in 24 hours.
- B. Patient uses the spirometer 10 times every hour.
- C. Patient's breath sounds are clear to auscultation.
- D. Patient's temperature is less than 38°C (100.4°F) orally.
Correct Answer: C
Rationale: One characteristic of ineffective airway clearance is the presence of adventitious breath sounds such as rhonchi or wheezes, so clear breath sounds are an indication of resolution of the problem. Spirometer use and increased fluid intake are interventions for ineffective airway clearance but may not improve breath sounds in all patients. Elevated temperature may occur with atelectasis, but a normal or near-normal temperature does not always indicate resolution of respiratory condition.
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The nurse is caring for a patient and during the second postoperative day after abdominal surgery, the nurse obtains an oral temperature of 38.2°C (100.8°F). Which of the following actions should the nurse take first?
- A. Have the patient use the incentive spirometer.
- B. Assess the surgical incision for redness and swelling.
- C. Administer the ordered PRN acetaminophen.
- D. Notify the patient's health care provider about the fever.
Correct Answer: A
Rationale: A temperature of 38.2°C (100.8°F) in the first 48 hours is usually caused by atelectasis, and the nurse should have the patient cough and deep breathe. This problem may be resolved by nursing intervention, and therefore notifying the health care provider is not necessary. Acetaminophen will reduce the temperature, but it will not resolve the underlying respiratory congestion. Because evidence of wound infection does not usually occur before the third postoperative day, assessment of the incision is not likely to be useful.
The nurse is caring for a patient who is being transferred from the postanesthesia care unit (PACU) to the clinical surgical unit. Which of the following actions should the nurse implement first on the clinical surgical unit?
- A. Assess the patient's pain.
- B. Take the patient's vital signs.
- C. Read the postoperative orders.
- D. Check the rate of the IV infusion.
Correct Answer: B
Rationale: Because the priority concerns after surgery are airway, breathing, and circulation, the vital signs are assessed first. The other actions should take place after the vital signs are obtained and compared with the vital signs before transfer.
The nurse is caring for an unconscious patient who was transferred to the postanaesthesia care unit (PACU) 10 minutes previously and has an oxygen saturation of 88%. Which of the following actions should the nurse take first?
- A. Elevate the patient's head.
- B. Suction the patient's mouth.
- C. Increase the oxygen flow rate.
- D. Perform the jaw-thrust manoeuvre or insert an oral airway.
Correct Answer: D
Rationale: In an unconscious postoperative patient, a likely cause of hypoxemia is airway obstruction by the tongue, and the first action is to clear the airway by manoeuvres such as the jaw thrust or chin lift. Increasing the oxygen flow rate and suctioning are not helpful when the airway is obstructed by the tongue. Elevating the patient's head will not be effective in correcting the obstruction but may help with oxygenation after the patient is awake.
After a new nurse has been oriented to the postanaesthesia care unit (PACU), the charge nurse will evaluate that the orientation has been successful when the new nurse does which of the following actions?
- A. Places a patient in the Trendelenburg position when the blood pressure (BP) drops.
- B. Assists a patient to the prone position when the patient is nauseated.
- C. Turns an unconscious patient to the side when the patient arrives in the PACU.
- D. Positions a newly admitted unconscious patient supine with the head elevated.
Correct Answer: C
Rationale: The patient should initially be positioned in the lateral 'recovery' position to keep the airway open and avoid aspiration. The prone position is not usually used and would make it difficult to assess the patient's respiratory effort and cardiovascular status. The Trendelenburg position is avoided because it increases the work of breathing. The patient is placed supine with the head elevated after regaining consciousness.
The nurse is caring for a patient who is recovering from anaesthesia in the postanaesthesia care unit (PACU), and the vital signs are blood pressure 118/72, pulse 72, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which of the following actions should the nurse take at this time?
- A. Place the patient in a side-lying position.
- B. Encourage the patient to take deep breaths.
- C. Prepare to transfer the patient from the PACU.
- D. Increase the rate of the postoperative IV fluids.
Correct Answer: B
Rationale: The patient's borderline SpO2 and sleepiness indicate hypoventilation. The nurse should stimulate the patient and remind the patient to take deep breaths. Placing the patient in a lateral position is needed when the patient first arrives in the PACU and is unconscious. The stable BP and pulse indicate that no changes in fluid intake are required. The patient is not fully awake and has a low SpO2, indicating that transfer from the PACU is not appropriate.