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:
A tingling sensation is not the primary concern when planning preoperative teaching for an amputation due to a severe gangrenous infection. While some patients may experience tingling due to nerve damage or as part of phantom limb sensation, the focus of preoperative teaching should be on managing pain and understanding the recovery process.

Choice B reason:
Telling a patient that their pain will gradually become less severe may be misleading. Post-amputation, patients often experience significant pain, including phantom limb pain, which can be intense and challenging to manage. Preoperative teaching should set realistic expectations about postoperative pain and its management.

Choice C reason:
Phantom pain is a real phenomenon experienced by many amputees, where they feel pain in the amputated limb as if it were still there. It is not merely psychological but has physiological underpinnings related to the nerves and brain's interpretation of signals. Preoperative teaching should include information about phantom limb pain, its potential occurrence, and strategies for managing it.

Choice D reason:
It is unrealistic to suggest that the pain will disappear soon after the amputation. Recovery from an amputation can be a lengthy process, and pain management is a critical component. Patients need to be prepared for the possibility of ongoing pain and the need for pain management strategies postoperatively.

A. Venous insufficiency B. Malnutrition C. Infection D. Continued pressure

Correct Answer is B

Explanation

Choice A reason:
Venous insufficiency can contribute to the development of chronic wounds, particularly in the lower extremities. It is characterized by the inability of the veins to adequately return blood from the legs back to the heart, which can lead to pooling of blood and increased pressure in the veins. This can cause skin changes and ulcers, particularly around the ankles.

Choice B reason:
Malnutrition is indeed a systemic cause of chronic wounds. Adequate nutrition is essential for wound healing, as it provides the necessary proteins, vitamins, and minerals that play a crucial role in the repair process. Protein-energy malnutrition, deficiencies in vitamins C and D, zinc, and other nutrients can impair wound healing and lead to chronic wounds.

Choice C reason:
Infection is typically a local rather than a systemic cause of chronic wounds. While systemic infections can affect wound healing, local wound infections are more directly responsible for delayed healing and the chronicity of wounds. Bacteria can colonize the wound and impede the healing process, leading to a chronic wound.

Choice D reason:
Continued pressure, much like infection, is generally a local cause of chronic wounds. It is most commonly associated with the development of pressure ulcers in individuals who are bedridden or have limited mobility. The constant pressure on certain areas of the body can lead to tissue ischemia and necrosis, resulting in a chronic wound.

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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 a severe gangrenous infection of the right lower extremity. The nurse should plan preoperative teaching based on the possibility of which of the following amputation procedures?

Correct Answer is C

Explanation

A nurse is caring for a client with a chronic wound. Which of the following is a systemic cause of chronic wounds?

Correct Answer is B

Explanation

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