The PACU nurse is caring for a patient who has arrived from the OR. During the initial assessment, the nurse observes that the patient's skin has become blue and dusky
The nurse looks, listens, and feels for breathing, and determines the patient is not breathing. What is the priority intervention?
A) Check the patient's oxygen saturation level, 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) Assess the arterial pulses, and place the patient in the Trendelenburg position.
D) Reintubate the patient.
Ans: B
Feedback:
When a nurse finds a patient who is not breathing, the priority intervention is to open the airway and treat a possible hypopharyngeal obstruction. To treat the possible airway obstruction, the nurse tilts the head back and then pushes forward on the angle of the lower jaw or performs the jaw thrust method to open the airway. This is an emergency and requires the basic life support intervention of airway, breathing, and circulation assessment. Arterial pulses should be checked only after airway and breathing have been established. Reintubation and resuscitation would begin after rapidly ruling out a hypopharyngeal obstruction.
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