A nurse in the PACU is caring for a client. Which of the following assessments is the nurse's priority?

Surgical site

Respiratory Status

Level of consciousness

Pain level

Answer and Explanation

The Correct Answer is B

B. This is often the nurse's top priority in the PACU. Anesthesia can depress respiratory function, leading to hypoventilation or airway obstruction. The nurse assesses respiratory rate, effort, oxygen saturation, and auscultates breath sounds to ensure adequate ventilation. Addressing any respiratory compromise promptly is crucial to prevent hypoxia or respiratory arrest.

A Assessing the surgical site is important to monitor for bleeding, infection, or any other complications related to the procedure. However, immediately after surgery, other assessments take precedence over this unless there is a specific concern like excessive bleeding or signs of infection.

C. Monitoring the client's level of consciousness is vital to detect any signs of neurological complications or delayed emergence from anesthesia. The nurse assesses orientation, responsiveness, and neurological signs to ensure the client is awakening appropriately from anesthesia.

D. Assessing pain is important as clients may experience discomfort after surgery. Pain can also affect respiratory function and overall recovery. However, it is typically assessed after ensuring respiratory status and consciousness are stable, as uncontrolled pain can be managed once immediate physiological concerns are addressed.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A While this statement is factual, it may come off as dismissive of the client’s concerns. The client may feel that their feelings and autonomy are not being respected. It's important to provide education but also to engage the client in a conversation about their concerns.

B. While this statement is intended to provide reassurance and encouragement, it may not be accurate for all clients or situations. It could also oversimplify the client's concerns and may not address the specific reasons for their reluctance to take the medication.

C. This response emphasizes the potential consequences of not adhering to the prescribed treatment plan. It highlights the importance of the medication in managing or treating the client's condition effectively. However, it may come across as threatening or coercive, which is not conducive to building a trusting and collaborative relationship with the client.

D. This is an appropriate response as it acknowledges the client’s autonomy and concern. It indicates that the nurse respects the client’s wishes and that the client will have the opportunity to discuss their concerns further with the provider. This fosters open communication and may lead to a better understanding of the necessity of the medication.

A. Raise the drainage system to the client's chest level. B. Clamp the tubing to check for air leaks. C. Empty the collection chamber. D. Gently squeeze the tubing to remove excess drainage.

Correct Answer is B

Explanation

B. The appropriate action for a nurse to take would be to check for air leaks in the system. This can be done by clamping the tubing momentarily to see if the bubbling stops, which would suggest the presence of a leak.

A The drainage system should always be kept below the level of the chest and should not be raised or emptied unless specifically indicated.

C. Emptying the collection chamber is typically unnecessary unless it is nearing full capacity. Continuous bubbling in the water seal chamber does not indicate that the collection chamber needs immediate emptying.

D. Squeezing the tubing can disrupt the functioning of the drainage system and is not recommended. Drainage should flow passively into the collection chamber without external manipulation.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse in the PACU is caring for a client. Which of the following assessments is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has been prescribed an antibiotic. The client tells the nurse, "I don't like taking medications because I don't think I need them." Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is caring for a client who has a chest tube in the pleural space. The nurse notices continuous bubbling in the water seal chamber of the client's drainage system. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is admitting a client who has meningitis. Which of the following findings should the nurse expect?

A nurse is teaching a client who has left-sided weakness how to use a quad cane. Which of the following client actions indicates an understanding of the teaching?

A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include?

A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are resting on the floor. Which of the following actions should the nurse take?

A nurse is caring for a client immediately following a cardiac catheterization through the right femoral artery. Which of the following actions should the nurse take?

Exhibits Which of the following 3 provider prescriptions does the nurse anticipate?

A nurse is providing teaching to a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication?