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 C
Explanation
Choice A reason: Having a glass of juice the morning of surgery may not be allowed, depending on the preoperative fasting guidelines. This statement could indicate a need for further clarification on preoperative instructions, but it is less critical than the misconception about eating solid food postoperatively.
Choice B reason: Taking time to relax if nervous the night before surgery is a healthy coping mechanism and does not indicate a lack of understanding about the surgery.
Choice C reason: The belief that the client will be able to eat solid food immediately after waking up from anesthesia is incorrect and indicates a need for further teaching. Postoperative dietary restrictions are typically in place, starting with clear liquids and gradually progressing to solid foods as tolerated.
Choice D reason: Understanding the risks associated with the surgery indicates that the client has received and comprehended the relevant information about the procedure.
Correct Answer is B
Explanation
Choice A reason: Increasing need for pain medication is not a typical outcome expected when a client is educated about their new colostomy. Proper education can help manage and reduce pain through better understanding and care techniques. The objective is often to reduce discomfort by teaching clients how to care for their colostomy properly, thus reducing complications and the associated pain.
Choice B reason: Report of empowerment is the expected outcome. Education aims to make the client feel capable and confident in managing their new condition. Empowerment indicates that the client understands their condition and feels confident in their ability to manage their colostomy, which can improve their overall quality of life and reduce the psychological impact of the procedure. Empowerment also helps in reducing the dependency on healthcare professionals and promotes self-care.
Choice C reason: An increase in the length of care in the healthcare facility is not an expected outcome. Proper patient education should ideally reduce the length of stay in the healthcare facility by equipping the client with the knowledge and skills needed to manage their colostomy at home, thus reducing the need for prolonged hospital stays.
Choice D reason: Reporting of anxiety is not the desired outcome. While some initial anxiety might be expected, the goal of patient education is to reduce anxiety by providing the client with the necessary information and skills to feel confident in managing their colostomy. Effective education should help alleviate anxiety by addressing concerns and providing support and reassurance.
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