A nurse is assessing a client who is being admitted from the Post-Anesthesia Care Unit (PACU) following an abdominal hysterectomy. Which of the following assessments is the nurse's priority?
Urinary output
Oxygen saturation
Abdominal dressing
Pain level
The Correct Answer is B
Choice A reason:
While monitoring urinary output is important after surgery to ensure kidney function and that the urinary tract has not been compromised during surgery, it is not the immediate priority. The nurse should ensure that the client is not experiencing postoperative complications such as urinary retention, but this comes after the assessment of vital signs.
Choice B reason:
Oxygen saturation is the priority assessment for a client being admitted from the PACU following an abdominal hysterectomy. Maintaining adequate oxygenation is critical after anesthesia, as respiratory function can be compromised. The nurse must ensure the client's airway is clear and that they are receiving sufficient oxygen to prevent hypoxia and other respiratory complications.
Choice C reason:
Inspecting the abdominal 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:
Pain management is a significant part of postoperative care, and the nurse will need to assess the client's pain level to manage it effectively. However, the immediate priority is to ensure the client's vital signs are stable, which includes oxygen saturation, before addressing pain.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Disinfecting equipment contaminated with blood or body fluids is crucial to prevent the spread of infection, but the specific time frame of twenty-four hours is not standard practice. The Centers for Disease Control and Prevention (CDC) recommends cleaning and then disinfecting surfaces or objects that may be contaminated, using a disinfectant registered by the Environmental Protection Agency (EPA) and following the manufacturer's instructions for use.
Choice B reason:
Burning soiled dressings is not a recommended practice due to environmental concerns and potential health risks associated with burning medical waste. Instead, soiled dressings should be disposed of properly in accordance with local regulations for biohazardous waste.
Choice C reason:
Good household cleaning practices are essential for preventing the spread of infection, especially for individuals with compromised immune systems, such as those with AIDS. Regular cleaning and disinfecting of frequently touched surfaces can help reduce the risk of infection.
Choice D reason:
The statement "Food preparation is not your responsibility" is not an appropriate discharge instruction. Patients with AIDS should be informed about safe food handling practices to prevent foodborne illnesses, which they are at higher risk for due to their weakened immune systems.
Correct Answer is ["B","C","E"]
Explanation
Choice A reason:
Increased hematocrit levels are not typically associated with fluid overload. In fact, hematocrit may decrease in fluid overload due to hemodilution, where the volume of plasma increases, diluting the concentration of red blood cells.
Choice B reason:
An increased respiratory rate can be a sign of fluid overload. As fluid accumulates in the body, it can lead to pulmonary edema, which is the buildup of fluid in the lung's air sacs. This can impair gas exchange and lead to increased respiratory rate as the body attempts to compensate for reduced oxygenation.
Choice C reason:
Increased blood pressure is a common finding in fluid overload. As the volume of fluid in the bloodstream increases, it can lead to higher blood pressure due to the extra fluid that the heart must pump and the increased resistance in the blood vessels.
Choice D reason:
Increased temperature is not a direct finding associated with fluid overload. While fever may indicate an infection or other conditions, it is not specifically related to the volume of fluid in the body.
Choice E reason:
An increased heart rate may occur in fluid overload as the heart works harder to pump the excess volume of blood through the body. This compensatory mechanism aims to maintain adequate circulation and blood pressure despite the increased fluid volume.
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