FREE ABPANC Physiological Needs Questions and Answers
A patient in the PACU exhibits signs of airway obstruction, including snoring and decreased oxygen saturation. What is the nurse's immediate action?
Snoring and decreased oxygen saturation are classic signs of airway obstruction caused by the tongue falling back. The nurse’s immediate priority is to open the airway by repositioning the patient’s head and neck (e.g., jaw thrust or head tilt-chin lift). If ineffective, further interventions like suctioning or escalating care may be necessary.
A patient recovering from general anesthesia becomes restless, tachycardic, and has a blood pressure of 180/95 mmHg. What is the most likely cause of these symptoms?
Hypoxia (low oxygen levels) is a common cause of restlessness, tachycardia, and hypertension in the PACU. The body responds to decreased oxygen by increasing the heart rate and blood pressure to compensate. The nurse should immediately assess oxygenation (e.g., pulse oximetry) and provide supplemental oxygen as needed.
A PACU patient reports severe nausea after receiving opioid pain medication. What is the nurse's priority intervention?
The priority in a patient with nausea is to prevent aspiration by positioning them on their side. After ensuring safety, the nurse should then administer an antiemetic as prescribed. Managing opioid side effects like nausea is essential for patient comfort and safety.
A patient’s temperature in the PACU drops to 35.5°C (95.9°F). What is the most appropriate nursing intervention?
Hypothermia (core temperature <36°C or 96.8°F) is common post-anesthesia. Applying active warming methods such as warm blankets or forced-air warming devices is the most appropriate initial intervention. Close temperature monitoring ensures the patient responds effectively to the intervention.
A post-operative patient’s urine output is 20 mL/hr for the last 2 hours. What is the nurse’s first action?
The nurse’s first step is to assess fluid balance to identify possible causes of decreased urine output (e.g., hypovolemia, low IV rate). Decreased urine output (<30 mL/hr) may indicate poor perfusion or dehydration. Proper assessment guides the next intervention, such as increasing IV fluids or notifying the physician.