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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Emptying the appliance daily at bedtime is not frequent enough to prevent leakage and ensure comfort, especially if the bag fills up during the day or night.
Choice B reason: Emptying the appliance twice a day may not be sufficient, depending on the amount of urine output. It could lead to overfilling and leakage.
Choice C reason: Waiting until the bag is full can increase the risk of leakage and discomfort. It is essential to empty the bag before it gets too full.
Choice D reason: Emptying the appliance when it is 2/3 full is the recommended practice. This prevents overfilling, reduces the risk of leakage, and ensures the client's comfort and hygiene.
Correct Answer is D
Explanation
Choice A reason: Reinserting the tube without confirming its correct placement can cause harm or lead to complications. It is not the nurse's role to reinsert the tube without proper verification.
Choice B reason: Repositioning the tube without verifying its placement could also cause harm. Ensuring correct placement should be done before any attempts to reposition the tube.
Choice C reason: Documenting the findings and administering feedings without confirming the tube's correct placement can result in serious complications, such as feeding into the wrong location.
Choice D reason: Notifying the healthcare provider immediately is the appropriate action. The provider can order verification of tube placement, such as through an X-ray, to ensure it is correctly positioned before any feedings are administered.
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