A nurse is admitting a client to the surgical unit from the Post-Anesthesia Care Unit (PACU) following a cholecystectomy. Which of the following assessments is the nurse's priority?
Bowel sounds
Oxygen saturation
Surgical dressing
Temperature
The Correct Answer is B
Choice A reason:
Bowel sounds are an important assessment to determine the return of gastrointestinal function after surgery. However, they are not the immediate priority following a cholecystectomy. The nurse will monitor bowel sounds to assess for ileus or obstruction, but this comes after ensuring that the patient's vital signs are stable.
Choice B reason:
Oxygen saturation is the priority assessment for a client being admitted from the PACU following a cholecystectomy. Ensuring adequate oxygenation is crucial after anesthesia, as respiratory function can be compromised. Monitoring oxygen saturation helps to detect hypoxemia early and prevent respiratory complications.
Choice C reason:
Inspecting the surgical dressing is necessary to check for signs of bleeding or infection at the surgical site. However, this is not the first priority upon admission from the PACU. The nurse will assess the dressing after vital signs and oxygen saturation have been addressed.
Choice D reason:
Temperature is an important vital sign that can indicate infection or other postoperative complications. However, the immediate priority is to ensure the client's airway and breathing are adequate, which includes assessing oxygen saturation before temperature.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
The location of the burn is crucial in assessing the severity because burns to the face, neck, and upper extremities can compromise vital functions. For example, burns to the face may affect the airway and respiratory system, while burns to the hands can impair mobility and the ability to perform daily tasks. The depth of the burn at these locations also affects the severity assessment, as deeper burns can damage underlying tissues and structures.
Choice B reason:
While the age of the client can influence the healing process and the risk of complications, it is not the primary factor in assessing the initial severity of the burn. However, age is considered when planning treatment and rehabilitation, as children and the elderly may have different healing rates and responses to therapy.
Choice C reason:
The cause of the burn can provide context for potential complications, such as inhalation injury from a fire or chemical exposure. However, the immediate assessment of severity is more focused on the observable damage to the skin and underlying tissues rather than the cause of the burn.
Choice D reason:
The client's associated medical history is important for understanding potential risks and complications during the healing process, but it is not the primary factor in assessing the severity of the burn. The medical history will be more relevant when considering the client's overall prognosis and planning long-term care.
Correct Answer is C
Explanation
Choice A reason:
Adjusting the rate of the bladder irrigant may be necessary if there is an issue with the flow or the amount of fluid, but it is not the first action to take. The nurse must first ensure that there is no mechanical obstruction causing the lack of drainage.
Choice B reason:
Irrigating the catheter could be the next step if checking the tubing does not resolve the issue. However, it is not the first action to take because if there is a kink in the tubing, irrigation will not be effective and could potentially cause harm.
Choice C reason:
The first action the nurse should take is to check the tubing for kinks because this is a common and easily correctable cause of obstruction in catheter drainage. If the tubing is kinked, straightening it may allow urine to drain properly.
Choice D reason:
Notifying the provider is important if the other interventions do not resolve the issue. However, it is not the first action to take. The nurse should first perform basic troubleshooting steps to identify and correct any simple mechanical issues with the catheter system.
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