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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason:
In the case of burns to the face and chest, assessing for inhalation injuries is critical due to the potential for airway compromise. Inhalation injuries can lead to significant respiratory distress and are considered a high priority in burn care. Inspecting the mouth for soot, burns, or edema can provide immediate information about the potential for respiratory complications, which can be life-threatening.

Choice B reason:
While monitoring urine output is important in burn patients for assessing fluid balance and kidney function, it is not the immediate priority. The insertion of an indwelling urinary catheter can be performed after stabilizing the airway and ensuring the patient is breathing adequately.

Choice C reason:
A CBC count is important for evaluating the patient's overall health status and can indicate the presence of infection or anemia. However, it is not the first action to take in the emergency setting where immediate life-saving interventions are prioritized.

Choice D reason:
Administering intravenous pain medication is important for patient comfort and can facilitate further care, but it is not the first priority. The initial focus should be on life-saving measures such as securing the airway and assessing for inhalation injuries.

A. "Eating a high fiber diet will reduce my risk for developing skin cancer." B. "I should avoid the use of tanning booths." C. "I should use sunscreen even on cloudy days." D. "I should check my skin monthly for any changes."

Correct Answer is A

Explanation

Choice A reason:
The statement about eating a high fiber diet reducing the risk for developing skin cancer is misleading. While a high fiber diet has many health benefits, there is no direct evidence that it significantly reduces the risk of skin cancer. Skin cancer prevention primarily focuses on protecting the skin from excessive sun exposure and avoiding ultraviolet (UV) light sources.

Choice B reason:
Avoiding the use of tanning booths is correct advice. Tanning booths emit UV radiation, which can increase the risk of skin cancer, including melanoma, the deadliest form of skin cancer. The use of tanning beds is strongly discouraged by health professionals.

Choice C reason:
Using sunscreen even on cloudy days is also correct. UV rays can penetrate through clouds, and sun protection is necessary regardless of the weather to reduce the risk of skin cancer. Sunscreen should be applied to all exposed skin and reapplied regularly, especially after swimming or sweating.

Choice D reason:
Checking the skin monthly for any changes is an important part of skin cancer prevention. Early detection of changes in moles or new skin growths can lead to early diagnosis and treatment, which is crucial for a better prognosis. This practice should be encouraged as part of routine self-care.

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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?

Nursing Test Bank

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