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

Answer and Explanation

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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Correct Answer is ["A","B","C"]

Explanation

Choice A reason:
Herpes zoster lesions are indeed contagious if they are draining. The virus can spread through direct contact with the fluid from the blisters. It is crucial to cover the lesions to prevent spreading the virus to others, especially to those who have never had chickenpox or the vaccine.

Choice B reason:
The development of vesicles, which are small fluid-filled blisters, is a hallmark of herpes zoster. These vesicles typically appear in a band-like pattern on one side of the body and are often accompanied by pain, itching, or tingling before they are visible.

Choice C reason:
Postherpetic neuralgia is a condition where the pain persists in the area of the herpes zoster rash even after the lesions have healed. This can last for weeks, months, or even years and is more common in older adults.

Choice D reason:
Herpes zoster itself is not spread like chickenpox. It occurs when the varicella-zoster virus, which has been lying dormant in the nerve cells, reactivates. While it is possible for someone who has never had chickenpox to develop chickenpox after direct contact with a shingles rash, herpes zoster is not "easily spread" to others in the same way that chickenpox is.

A. Notify the client that they will receive a food tray in the recovery room. B. Remind the client they will return to their room after surgery. C. Inform the client that the recovery nurse will instruct them on how to manage postoperative pain. D. Provide instructions about how to cough and deep breathe effectively.

Correct Answer is D

Explanation

Choice A reason:
Notifying the client that they will receive a food tray in the recovery room is not typically a priority in preoperative education. Nutritional status post-surgery is important, but immediate postoperative care focuses on recovery from anesthesia and monitoring for complications.

Choice B reason:
Reminding the client that they will return to their room after surgery is part of routine information that may help orient the patient postoperatively. However, it is not a specific intervention that will aid in the recovery process or prevent complications.

Choice C reason:
Informing the client that the recovery nurse will instruct them on how to manage postoperative pain is important, but it is not the primary focus of preoperative education. Pain management is typically addressed both preoperatively and postoperatively.

Choice D reason:
Providing instructions on how to cough and deep breathe effectively is a critical component of preoperative education for clients undergoing abdominal surgery. Effective coughing and deep breathing exercises help prevent postoperative complications such as pneumonia and atelectasis by promoting lung expansion and secretion clearance.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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