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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.
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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 just waking up after having a general anaesthetic and the patient is agitated and confused. Which of the following actions should the nurse take first?
- A. Check the O2 saturation.
- B. Administer the ordered opioid.
- C. Take the blood pressure and pulse.
- D. Notify the anaesthesia care provider.
Correct Answer: A
Rationale: Emergence delirium may be caused by a variety of factors. However, the nurse should first assess for hypoxemia. The other actions also may be appropriate, but are not the best initial action.
The nurse is caring for a postoperative patient who has not voided for 7 hours after return to the postsurgical unit. Which of the following actions should the nurse take first?
- A. Notify the surgeon.
- B. Assess for bladder distension.
- C. Assist the patient to ambulate to the bathroom.
- D. Insert a straight catheter as indicated on the PRN order.
Correct Answer: B
Rationale: The initial action should be to assess the bladder for distension. If the bladder is distended, providing the patient with privacy (by walking with them to the bathroom) will be helpful. Catheterization should only be done after other measures have been tried without success because of the risk for urinary tract infection. There is no indication to notify the surgeon about this common postoperative problem unless all measures to empty the bladder are unsuccessful.
The nurse is caring for a patient in the postoperative period who is on bed rest. Which of the following actions should the nurse implement?
- A. Assist the patient to the bathroom when required.
- B. Implement active ROM exercise every 1-2 hours.
- C. Place the patient in a chair for 20 minutes TID.
- D. Complete passive ROM exercises once per 12 hour shift.
Correct Answer: B
Rationale: When confined to bed, patients should alternately flex and extend all joints 10-12 times every 1-2 hours while awake. The muscular contraction produced by these exercises and by ambulation facilitates venous return from the lower extremities. A patient on bed rest is not to be assisted up to the bathroom or placed in a chair. If passive ROM exercise were to be completed, the frequency would be every 1-2 hours, not once per 12 hour shift.
The nurse is caring for a patient on the first postoperative day who is dizzy when ambulating in the room. In what order will the nurse accomplish the following activities? (All the activities are appropriate.)
- A. Take the patient's blood pressure (BP).
- B. Place the patient in the supine position.
- C. Assist the patient to sit and repeat 5 minutes later.
- D. Record the results.
Correct Answer: B,A,C,D
Rationale: The first priority for the patient with syncope is to prevent a fall, so the patient should be placed in the supine position. Assessment of the BP will determine whether the dizziness is due to orthostatic hypotension, which occurs because of hypovolemia. After taking BP, the patient is assisted to the sitting position and the BP is rechecked in 1-3 minutes. Because this is a common postoperative problem that is usually resolved through nursing measures such as increasing fluid intake and making position changes more slowly, there is no need to notify the health care provider and the nurse is to record the results of the assessment.