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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Related Questions
Correct Answer is C
Explanation
Choice A reason:
Informatics involves the use of information technology in healthcare, which is essential for managing patient data and improving communication. However, while informatics supports various aspects of patient care, it is not the primary concern during the perioperative period. The focus during this time is on ensuring the client's immediate well-being and preventing harm.
Choice B reason:
Quality improvement is a continuous process of identifying and implementing changes to improve patient care and outcomes. While it is a critical component of nursing practice, the priority in the perioperative period is the safety of the client, which is a more immediate concern.
Choice C reason:
Safety is the most critical QSEN competency during the perioperative period. This period involves significant risks due to anesthesia, surgical procedures, and potential complications. Ensuring the client's safety by preventing errors, reducing the risk of harm, and maintaining a sterile environment is paramount.
Choice D reason:
Evidence-based practice involves using the best current evidence to make informed decisions about patient care. While it is crucial for guiding clinical practice, the immediate priority in the perioperative period is ensuring the client's safety through vigilant monitoring and intervention.
Correct Answer is A
Explanation
Choice A reason: Drink 3L of fluid every day
Drinking adequate fluids, especially water, is one of the most effective ways to prevent kidney stones. Fluids dilute the substances in urine that lead to stones. For someone with a history of kidney stones, drinking about 3 liters of water each day can help prevent stone formation¹².
Choice B reason: Take 3,000 mg of vitamin C daily
High doses of vitamin C can increase the risk of kidney stones as the body converts vitamin C into oxalate, which can then form stones. Therefore, taking 3,000 mg of vitamin C daily is not recommended for individuals prone to calcium oxalate stones².
Choice C reason: Restrict calcium intake to one serving per day
Contrary to what might seem intuitive, restricting calcium intake is not generally advised for preventing calcium oxalate stones. Adequate dietary calcium can help reduce the amount of oxalate being absorbed by the body, thus lowering the risk of stone formation. It's important to consume calcium-rich foods in moderation and not to restrict them severely.
Choice D reason: Eat 12 oz of animal protein daily
A high intake of animal protein can increase the risk of kidney stones in susceptible individuals. Animal protein can increase calcium and oxalate levels in urine and reduce levels of citrate, a substance that prevents stones. Therefore, it's recommended to limit animal protein intake rather than consume large amounts.
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