A nurse is admitting a client to the surgical unit from the PACU following a cholecystectomy. Which of the following assessments is the nurse's priority?
Bowel sounds
Temperature
Surgical dressing
Oxygen saturation
The Correct Answer is D
Choice A reason: Assessing bowel sounds is important for postoperative care, especially after abdominal surgery, but it is not the immediate priority upon admission from the PACU.
Choice B reason: Monitoring temperature is essential to detect signs of infection or other complications, but it is not the immediate priority right after surgery.
Choice C reason: Checking the surgical dressing for bleeding or signs of infection is important, but maintaining adequate oxygen saturation takes precedence immediately post-surgery.
Choice D reason: Oxygen saturation is the priority assessment because it ensures that the patient is receiving adequate oxygenation after surgery. Respiratory complications are common postoperatively, and ensuring proper oxygenation is crucial for patient safety.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: While auscultating the client's lungs is important for overall assessment, it is not the immediate priority following pain management in acute pancreatitis.
Choice B reason: Providing oral hygiene is important for comfort and preventing infections but is not the immediate priority.
Choice C reason: Assisting the client to a side-lying position can help with comfort and prevent aspiration, but it is not the most critical intervention following pain management.
Choice D reason: Withholding oral fluids and food is the priority intervention to reduce pancreatic stimulation and enzyme secretion, which can exacerbate the inflammation and pain in acute pancreatitis. This intervention helps rest the pancreas and promote healing.
Correct Answer is C
Explanation
Choice A reason: Cleaning the inside of the container with a wipe is not part of the standard procedure for collecting a midstream urine sample. The focus should be on maintaining external cleanliness to avoid contamination of the sample.
Choice B reason: Urinating a little then stopping is part of the process, but this statement alone does not indicate a complete understanding of the procedure. The critical aspect is how the client cleans and collects the sample to ensure it is not contaminated.
Choice C reason: Using the cleansing wipe from front to back is the correct procedure for collecting a midstream urine sample. This method helps prevent contamination from bacteria that could be present around the genital area, ensuring a more accurate sample for analysis.
Choice D reason: Using each cleansing wipe twice is not advised as it can lead to contamination. Each wipe should be used only once to maintain hygiene and ensure the accuracy of the urine sample.
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