Question

An unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU) 15 minutes ago has an oxygen saturation of 89%. Which action should the nurse take first?

Answer 1

Correct Answers:

Perform the jaw-thrust maneuver.

Rationale :

The jaw-thrust maneuver is the best method for opening the airway of an unconscious patient, especially post-surgery, without moving the cervical spine. A low oxygen saturation (89%) suggests inadequate oxygenation, which is best managed by ensuring a patent airway first before increasing oxygen flow.

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Answer 2

Correct Answers:

Instruct the client to wiggle his toes.

Rationale :

Neurovascular status is assessed by checking motor function, and asking the patient to wiggle their toes helps assess movement and nerve function. Other methods, such as pulse checks and measuring thigh circumference, do not directly assess motor function or nerve integrity.

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Answer 3

Correct Answers:

Redness and swelling along the suture line

Rationale :

Redness and swelling at the surgical site are early signs of infection, which require immediate reporting to prevent wound complications. Other findings, such as low-grade fever and sanguineous drainage, are expected in the immediate postoperative period.

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Answer 4

Correct Answers:

A synthetic cast is weighs less.

Rationale :

Synthetic casts (fiberglass) are lighter and more durable than traditional plaster casts, making them easier for patients to manage. Plaster casts take longer to dry and are more fragile compared to synthetic options.

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Answer 5

Correct Answers:

Realign the clients position.

Rationale :

Muscle spasms in traction often occur due to misalignment, so repositioning the client can reduce discomfort without additional medication. Pain control should always begin with non-pharmacological interventions before medication adjustments.

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Answer 6

Correct Answers:

Hold the wrist at a 90-degree flexion.

Rationale :

The Phalen’s test is used to diagnose carpal tunnel syndrome by having the patient hold wrist flexion at 90 degrees for 60 seconds, which reproduces symptoms. Other positions, such as arm extension or elbow flexion, do not assess for median nerve compression.

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Answer 7

Correct Answers:

Prevent hip flexion of the affected extremity

Rationale :

Excessive hip flexion (>90 degrees) can cause hip dislocation after a total hip arthroplasty, so preventing this movement is a priority. Legs should not be positioned together or touching to prevent internal rotation and excessive pressure on the new joint.

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Answer 8

Correct Answers:

Continue to prepare the patient for the surgical procedure.

Rationale :

The WBC count (10.2), hemoglobin (15), hematocrit (45%), and platelets (150) are all within normal ranges, meaning surgery can proceed as planned. There is no indication of active infection or abnormal coagulation that would require notifying the surgeon.

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Answer 9

Correct Answers:

Aging
Obesity

Rationale :

Aging is a major risk factor for osteoarthritis due to wear and tear on joints over time. Obesity increases stress on weight-bearing joints, leading to cartilage breakdown and inflammation.

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Answer 10

Correct Answers:

The right time
The right medication
The right dose
The right patient

Rationale :

The 5 rights of medication administration include right patient, right medication, right dose, right route, and right time. Medication color and taste are not part of safe medication practices.

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QLexNursing

1 : An unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU) 15 minutes ago has an oxygen saturation of 89%. Which action should the nurse take first?

2 : A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the clients neurovascular status?

3 : The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon?

4 : A nurse is teaching a newly licensed nurse about the difference between a plaster cast and a synthetic cast. Which of the following information should the nurse include in the teaching?

5 : A nurse is caring for a client who has a fractured right femur and is in balanced suspension traction. The client is reporting pain from muscle spasms. Which of the following actions should the nurse take first?

7 : A nurse is planning care for a client who is postoperative following a total hip arthroplasty. Which of the following interventions should the nurse include in the plan of care?

8 : The outpatient surgery nurse reviews the complete blood cell (CBC) count results for a patient who is scheduled for surgery. The results are white blood cell (WBC) count 10.2 x 103/pL;

hemoglobin 15 g/dL; hematocrit 45%; platelets 150 x 103/pL. Which action should the nurse take?

9 : A nurse is teaching a client about risk factors for osteoarthritis. Which of the following factors should the nurse include in the teaching? (Select all that apply.)

10 : Which of the following statements accurately describe the medication rights? (Select All that Apply.)

QLexNursing

1 : An unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU) 15 minutes ago has an oxygen saturation of 89%. Which action should the nurse take first?

2 : A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the clients neurovascular status?

3 : The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon?

4 : A nurse is teaching a newly licensed nurse about the difference between a plaster cast and a synthetic cast. Which of the following information should the nurse include in the teaching?

5 : A nurse is caring for a client who has a fractured right femur and is in balanced suspension traction. The client is reporting pain from muscle spasms. Which of the following actions should the nurse take first?

7 : A nurse is planning care for a client who is postoperative following a total hip arthroplasty. Which of the following interventions should the nurse include in the plan of care?

8 : The outpatient surgery nurse reviews the complete blood cell (CBC) count results for a patient who is scheduled for surgery. The results are white blood cell (WBC) count 10.2 x 103/pL;hemoglobin 15 g/dL; hematocrit 45%; platelets 150 x 103/pL. Which action should the nurse take?

9 : A nurse is teaching a client about risk factors for osteoarthritis. Which of the following factors should the nurse include in the teaching? (Select all that apply.)

10 : Which of the following statements accurately describe the medication rights? (Select All that Apply.)

8 : The outpatient surgery nurse reviews the complete blood cell (CBC) count results for a patient who is scheduled for surgery. The results are white blood cell (WBC) count 10.2 x 103/pL;

hemoglobin 15 g/dL; hematocrit 45%; platelets 150 x 103/pL. Which action should the nurse take?