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

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A reason: Reducing the client's intake of protein can help decrease the production of ammonia, which is a byproduct of protein metabolism. High ammonia levels contribute to hepatic encephalopathy, so a lower protein diet can be beneficial.
Choice B reason: Administering vitamin K is important for managing bleeding risks associated with cirrhosis, but it does not specifically address ammonia levels.
Choice C reason: Restricting fluid intake may be necessary for managing ascites and edema in cirrhosis but does not directly impact ammonia levels.
Choice D reason: Administering diuretics is often necessary to manage fluid retention and ascites, but it does not affect ammonia production or levels in the blood.

A. You will wear an external collection bag to drain your urine. B. You will have an internal pouch to store your urine. C. You will not be able to control your urination. D. You will have a stoma that is located in your abdomen.

Correct Answer is B

Explanation

Choice A reason: Wearing an external collection bag is typically associated with other types of urinary diversions, such as an ileal conduit, not a neobladder.
Choice B reason: A neobladder involves the creation of an internal pouch from a segment of the intestine that stores urine and allows for more natural urination, similar to the function of a natural bladder. This option provides the ability to void through the urethra.
Choice C reason: While some initial incontinence can occur after neobladder surgery, the goal is to eventually have voluntary control over urination with time and practice.
Choice D reason: Having a stoma located in the abdomen is characteristic of an ileal conduit or urostomy, not a neobladder. The neobladder is designed to avoid the need for an external stoma.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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