Free ABPANC Physiological Needs Questions and Answers — Questions and Answers
Question 1: A patient in the PACU exhibits signs of airway obstruction, including snoring and decreased oxygen saturation. What is the nurse's immediate action?
- Increase the oxygen flow rate via face mask.
- Suction the patient’s airway.
- Reposition the patient’s head and neck to open the airway. (Correct answer)
- Call for the anesthesiologist immediately.
Correct answer: Reposition the patient’s head and neck to open the airway.
Snoring and decreased oxygen saturation in a PACU patient often indicate an airway obstruction, most commonly due to the tongue falling back against the posterior pharynx. The immediate and least invasive action is to perform a head-tilt/chin-lift or jaw-thrust maneuver to reposition the head and neck. This simple intervention can effectively open the airway and often resolves the obstruction.
Question 2: 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?
- Hypovolemia
- Hypoxia (Correct answer)
- Pain
- Hypothermia
Correct answer: Hypoxia
Restlessness, tachycardia, and hypertension in a post-anesthesia patient are classic signs of hypoxia. The body responds to insufficient oxygen by increasing heart rate and blood pressure in an attempt to improve oxygen delivery to tissues. While pain can also cause these symptoms, hypoxia is a more critical and immediate concern that must be ruled out first due to its life-threatening potential.
Question 3: A PACU patient reports severe nausea after receiving opioid pain medication. What is the nurse's priority intervention?
- Administer an antiemetic as prescribed.
- Offer the patient sips of water or ginger ale.
- Turn the patient to their side to prevent aspiration. (Correct answer)
- Discontinue the opioid medication immediately.
Correct answer: Turn the patient to their side to prevent aspiration.
Severe nausea, especially after opioid administration, carries a significant risk of vomiting and subsequent aspiration, which can lead to life-threatening pneumonia. The priority intervention is to protect the patient's airway by turning them to their side, preventing gastric contents from entering the lungs if vomiting occurs. Administering antiemetics is important but secondary to ensuring immediate airway safety.
Question 4: A patient’s temperature in the PACU drops to 35.5°C (95.9°F). What is the most appropriate nursing intervention?
- Apply warm blankets and monitor the patient’s temperature closely. (Correct answer)
- Increase the IV fluid rate to warm the patient internally.
- Notify the physician immediately of the hypothermia.
- Place the patient in the Trendelenburg position.
Correct answer: Apply warm blankets and monitor the patient’s temperature closely.
A temperature of 35.5°C (95.9°F) indicates mild hypothermia, which is common after surgery due to anesthesia effects and exposure. The most appropriate initial nursing intervention is to apply passive rewarming measures like warm blankets to conserve heat and gradually raise the body temperature. Close monitoring ensures the intervention is effective and prevents further temperature drop.
Question 5: A post-operative patient’s urine output is 20 mL/hr for the last 2 hours. What is the nurse’s first action?
- Notify the physician of potential kidney failure.
- Assess the patient’s fluid intake and IV status. (Correct answer)
- Insert a Foley catheter to monitor output more closely.
- Increase the IV fluid rate to improve perfusion.
Correct answer: Assess the patient’s fluid intake and IV status.
A urine output of 20 mL/hr for two hours is low and warrants investigation, but it's crucial to first assess for common, reversible causes before escalating to physician notification or invasive procedures. Checking the patient's recent fluid intake, IV fluid rate, and ensuring the catheter (if present) is patent can reveal if the low output is due to dehydration or a mechanical issue. This systematic assessment helps determine the appropriate next step.
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?