When caring for a patient the second postoperative day after ...

[RYAN BANYAN]

When caring for a patient the second postoperative day after abdominal surgery for removal of a large pancreatic cyst, the nurse obtains an oral temperature of 100.8 F. Which action 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 (Tylenol).
  d. Ask the health care provider to prescribe a different antibiotic.

Question 2

The nurse assesses that the oxygen saturation is 89 in an unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU) 15 minutes ago. Which action 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 maneuver.

[Bison]

Answer to Question 1

ANS: A
A temperature of 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 a wound infection does not usually occur before the third postoperative day, a wound infection is not a likely source of the elevated temperature.

Answer to Question 2

ANS: D
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 maneuvers 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.

[RYAN BANYAN]

Correct answers!

[Bison]

Great! Please up vote