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
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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. The CPM machine should be used during designated therapy sessions as prescribed by the healthcare provider. Turning it off during meals allows the client to focus on eating without interference from the machine.
A The range of motion settings on the CPM machine should be adjusted gradually according to the client's tolerance and prescribed therapy plan. Rapidly increasing the range of motion could cause discomfort, pain, or even injury to the client's knee joint. Therefore, the nurse should not increase the range of motion rapidly.
B Storing the CPM machine on the floor is not ideal because it can increase the risk of contamination or damage to the equipment. The machine should be stored on a clean, stable surface when not in use to prevent accidental damage or exposure to dirt and debris.
D. Regular checks of the CPM machine's settings are important, but every 12 hours may not be frequent enough to ensure the machine is functioning correctly and safely.
Correct Answer is C
Explanation
C. Lowering the bed height reduces the risk of injury in case the client falls out of bed. It also facilitates easier transfers for clients with mobility issues.
A Individuals with dementia may experience disorientation and confusion, especially in unfamiliar or dark environments. Turning off all lights can increase the risk of falls and accidents.
B. Clients with dementia may have difficulty recognizing the need to toilet or may forget where the bathroom is located. They may also have urinary or fecal incontinence. Scheduled toileting helps prevent accidents and promotes continence.
D. Sedatives or hypnotic medications can increase confusion, risk of falls, and adverse effects in older adults with dementia. They are generally not recommended as first-line treatment for sleep disturbances in dementia.
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