The postanesthesia-care unit (PACU) nurse is caring for a patient who has arrived from the operating room and is still unconscious

Question

During the initial assessment, the nurse notices that the patient's skin is blue and dusky, so she looks, listens, and feels for breathing. She determines the patient is not breathing. The priority intervention is to:
A) Check an oxygen saturation rate, 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) Check the arterial pulses and place the patient in the Trendelenburg position.
D) Call a code blue and then get a rapid intubation kit and prepare to reintubate.

Answer 1

Ans: B
Feedback: When a nurse finds a patient who is not breathing, the priority intervention is to open the airway and treat the possible hypopharyngeal obstruction. To treat the possible airway obstruction, the nurse tilts the head back, pushes forward on the angle of the lower jaw, or performs the jaw thrust method to open the airway. Option A is incorrect; this is an emergency and requires the basic life support intervention of airway, breathing, and circulation assessment. Option C is incorrect; arterial pulses should be checked only after airway and breathing have been established. Option D is incorrect; calling a code blue is appropriate in this case and the patient may need to be reintubated, but the nurse should never leave the patient without an airway to get a rapid intubation kit and prepare for reintubation.