Nokea
The PACU nurse is caring for a patient who has arrived from the OR. During the initial assessment, the nurse observes that the patients skin has become blue and dusky. The nurse looks, listens, and feels for breathing, and determines the patient is not breathing. What is the priority intervention?
- A. Check the patients oxygen saturation level, continue to monitor for apnea, and perform a focused assessment
- B. Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw
- C. Assess the arterial pulses, and place the patient in the Trendelenburg position
- D. Reintubate the patient
Correct Answer: B
Rationale: When a nurse finds a patient who is not breathing, the priority intervention is to open the airway and treat a possible hypopharyngeal obstruction. To treat the possible airway obstruction, the nurse tilts the head back and then pushes forward on the angle of the lower jaw or performs the jaw thrust method to open the airway. This is an emergency and requires the basic life support intervention of airway, breathing, and circulation assessment. Arterial pulses should be checked only after airway and breathing have been established. Reintubation and resuscitation would begin after rapidly ruling out a hypopharyngeal obstruction.
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The nurse is caring for a patient who is postoperative day 2 following a colon resection. While turning him, wound dehiscence with evisceration occurs. What should be the nurses first response?
- A. Return the patient to his previous position and call the physician
- B. Place saline-soaked sterile dressings on the wound
- C. Assess the patients blood pressure and pulse
- D. Pull the dehiscence closed using gloved hands
Correct Answer: B
Rationale: The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. Then the nurse should call the physician and take the patients vital signs. The dehiscence needs to be surgically closed, so the nurse should never try to close it.
The nurse is caring for a postoperative patient who needs daily dressing changes. The patient is 3 days postoperative and is scheduled for discharge the next day. Until now, the patient has refused to learn how to change her dressing. What would indicate to the nurse the patients possible readiness to learn how to change her dressing? Select all that apply.
- A. The patient wants you to teach a family member to do dressing changes
- B. The patient expresses interest in the dressing change
- C. The patient is willing to look at the incision during a dressing change
- D. The patient expresses dislike of the surgical wound
- E. The patient assists in opening the packages of dressing material for the nurse
Correct Answer: B,C,E
Rationale: While changing the dressing, the nurse has an opportunity to teach the patient how to care for the incision and change the dressings at home. The nurse observes for indicators of the patients readiness to learn, such as looking at the incision, expressing interest, or assisting in the dressing change. Expressing dislike and wanting to delegate to a family member do not suggest readiness to learn.
You are caring for a 71-year-old patient who is 4 days postoperative for bilateral inguinal hernias. The patient has a history of congestive heart failure and peptic ulcer disease. The patient is highly reluctant to ambulate and will not drink fluids except for hot tea with her meals. The nurses aide reports to you that this patients vital signs are slightly elevated and that she has a nonproductive cough. When you assess the patient, you auscultate crackles at the base of the lungs. What would you suspect is wrong with your patient?
- A. Pulmonary embolism
- B. Hypervolemia
- C. Hypostatic pulmonary congestion
- D. Malignant hyperthermia
Correct Answer: C
Rationale: Hypostatic pulmonary congestion, caused by a weakened cardiovascular system that permits stagnation of secretions at lung bases, may develop; this condition occurs most frequently in elderly patients who are not mobilized effectively. The symptoms are often vague, with perhaps a slight elevation of temperature, pulse, and respiratory rate, as well as a cough. Physical examination reveals dullness and crackles at the base of the lungs. If the condition progresses, then the outcome may be fatal. A pulmonary embolism does not have this presentation and hypervolemia is unlikely due to the patients low fluid intake. Malignant hyperthermia occurs concurrent with the administration of anesthetic.
The nurse is caring for a patient who has just been transferred to the PACU from the OR. What is the highest nursing priority?
- A. Assessing for hemorrhage
- B. Maintaining a patent airway
- C. Managing the patients pain
- D. Assessing vital signs every 30 minutes
Correct Answer: B
Rationale: The primary objective in the immediate postoperative period is to maintain ventilation and, thus, prevent hypoxemia (reduced oxygen in the blood) and hypercapnia (excess carbon dioxide in the blood). Assessing for hemorrhage and assessing vital sign are also important, but constitute second and third priorities. Pain management is important but only after the patient has been stabilized.
The nurse is caring for a patient after abdominal surgery in the PACU. The patients blood pressure has increased and the patient is restless. The patients oxygen saturation is 97%. What cause for this change in status should the nurse first suspect?
- A. The patient is hypothermic
- B. The patient is in shock
- C. The patient is in pain
- D. The patient is hypoxic
Correct Answer: C
Rationale: An increase in blood pressure and restlessness are symptoms of pain. The patients oxygen saturation is 97%, so hypothermia, hypoxia, and shock are not likely causes of the patients restlessness.