The postoperative patient is admitted to the postanesthesia care unit (PACU) with an oral airway in place,an indwelling urinary catheter,IV fluid infusing via two different sites,and a Jackson-Pratt drain pinned to the gown near the wound dressing.What is the nurse's priority action after the patient is moved to the bed?

A) Check the wound dressing.
B) Obtain vital signs.
C) Turn the patient's head to the side.
D) Hang the urinary drainage bag on the bed frame.

Question

Caleb Thurmond · Accepted Answer

Final Answer : C , Explanation :  Based on the fact that an oral airway remains in place,it can be concluded that the patient's sedation level is high.Guarding the airway by turning the patient's head to drain secretions or possible emesis is the highest priority action to be performed by the nurse.Although assessing for drainage on the dressing is an important activity,it is not the first thing the nurse will do.Vital signs should be obtained,but that is not the first priority.Ensuring proper drainage from the urinary catheter is important,but is not the first priority.The only immediately life-threatening risk for this patient would be a compromised airway.

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