Nursing Prioritization Delegation Assignment Q 50
The nurse plans care for a client in the post-anesthesia care unit. Which of the following should the nurse assess first?
A. Respiratory status
B. Level of consciousness
C. Level of pain
D. Reflexes and movement of extremities
Correct Answer: A. Respiratory status
Assessing respiratory status is the first priority. Remember ABC. General anesthesia and mechanical ventilation impair pulmonary function, even in normal individuals, and result in decreased oxygenation in the postanesthesia period. They also cause a reduction in functional residual capacity of up to 50% of the preanesthesia value.
Option B: A level of consciousness assessment is also helpful, such as the AVPU scale or the Glasgow Coma Scale. The AVPU scale assesses if the patient is alert and oriented, responds to voice, responds to pain, or is unresponsive. The Glasgow Coma Scale is an objective way to record the conscious state of a patient, examining eye, verbal, and motor responses.
Option C: Pain is a common occurrence after most all types of surgical procedures and is probably the most significant postoperative problem in the eyes of the patient. Prompt and adequate pain relief is a critical nursing intervention.
Option D: Neurologic functions can be assessed by the patient’s response to verbal stimuli, pupils’ responsiveness to light and accommodation, ability to move all extremities, and strength and equality of a hand grip.