A nurse in the PACU is caring for a client.
Which of the following assessments is the nurse's priority?
Respiratory status.
Surgical site.
Level of consciousness.
Pain level.
The Correct Answer is A
The nurse’s priority assessment in the PACU (Post-Anesthesia Care Unit) should be the client’s respiratory status.
This is because the client is recovering from anesthesia and may have an altered respiratory function.
Choice B, assessing the surgical site, is not an answer because it is not the priority assessment for a client in the PACU.
Choice C, assessing the level of consciousness, is not an answer because it is not the priority assessment for a client in the PACU.
Choice D, assessing the pain level, is not an answer because it is not the priority assessment for a client in the PACU.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
“Fluid volume excess.” Bounding pulses, crackles on auscultation, and pink frothy secretions when receiving suctioning are all signs of fluid volume excess.
Fluid volume excess can occur when the heart is unable to pump blood efficiently, causing fluid to build up in the lungs.
Choice A is not the correct answer because the increased cardiac output would not cause these symptoms.
Choice B is not the correct answer because pleural effusion refers to a buildup of fluid between the layers of tissue that line the lungs and chest cavity, which would not cause these symptoms.
Choice D is not the correct answer because aspiration refers to the inhalation of food, liquid, or other substances into the lungs, which would not cause these symptoms.
Correct Answer is C
Explanation
This statement indicates an understanding of the teaching because it shows that the client is aware of the importance of reducing their risk of infection by taking precautions when handling pet waste.
Choice A is wrong because while increasing the amount of fresh fruits and vegetables consumed is a healthy dietary choice, it does not demonstrate an understanding of the discharge teaching for a client with AIDS.
Choice B is wrong because while cleaning up areas soiled with body fluids is important, using alcohol and immediately disposing of the trash is not necessary.
Choice D is wrong because taking clothes to the dry cleaners to sterilize them is not necessary for a client with AIDS.
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