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 C

Explanation

Choice A reason: Hypertension
Hypertension, or high blood pressure, is not typically an expected finding in hypovolemic shock. In fact, one would expect the opposite, hypotension, due to the decreased circulating blood volume. Hypertension might be present in the initial stages due to compensatory mechanisms, but as the condition progresses, blood pressure usually drops.

Choice B reason: Bradypnea
Bradypnea, or abnormally slow breathing, is not a common finding in hypovolemic shock. Instead, tachypnea, or rapid breathing, may be observed as the body attempts to compensate for reduced oxygen delivery to tissues.

Choice C reason: Oliguria
Oliguria, or low urine output, is an expected finding in hypovolemic shock. As the blood volume decreases, the kidneys receive less blood flow, leading to reduced urine production. This is a protective mechanism to conserve body fluids, but it also indicates the severity of fluid loss and the need for urgent intervention.

Choice D reason: Flushing of the skin
Flushing of the skin is not an expected finding in hypovolemic shock. Instead, the skin may appear pale, cool, and clammy due to vasoconstriction and reduced blood flow to the periphery as the body prioritizes blood flow to vital organs.

A. Hay fever allergy B. Anaphylaxis C. Transplant rejection D. Bacterial phagocytosis

Correct Answer is C

Explanation

Choice A reason:
Hay fever allergy, also known as allergic rhinitis, is primarily associated with the action of Immunoglobulin E (IgE) antibodies and not directly with T-cells. T-cells can contribute to the regulation of the immune response in allergies, but IgE is the main immunoglobulin involved in the typical symptoms of hay fever.

Choice B reason:
Anaphylaxis is a severe, potentially life-threatening allergic reaction that involves the release of large amounts of histamine and other chemicals from mast cells and basophils, often triggered by IgE antibodies. While T-cells can play a role in the sensitization phase of allergy, anaphylaxis itself is not directly caused by T-cells.

Choice C reason:
Transplant rejection is a process in which T-cells play a central role. When a transplant recipient's immune system recognizes the donated organ as foreign, T-cells can mediate the rejection by attacking the transplanted tissue, leading to its failure.

Choice D reason:
Bacterial phagocytosis is primarily the function of phagocytes like neutrophils and macrophages. T-cells are involved in the adaptive immune response and can activate phagocytes, but they do not directly perform phagocytosis.

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?

Correct Answer is C

Explanation

A nurse is assessing a client's immune function by reviewing the laboratory value of the cellular response of the T-cells. The nurse should recognize that which of the following conditions is affected by the T-cells?

Correct Answer is C

Explanation

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