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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Annular lesions are ring-shaped with a clear center, which does not describe a lesion with a wavy border. This term is typically used for lesions like ringworm, which present as circular rashes with normal skin in the center.
Choice B reason:
Circinate lesions are also circular but are not characterized by a wavy border. They are similar to annular lesions but often have a more rounded edge and are associated with conditions like psoriasis.
Choice C reason:
Coalesced lesions refer to multiple lesions that have merged to form a larger one. While they can have irregular borders, 'coalesced' does not specifically describe the wavy nature of the border.
Choice D reason:
Serpiginous lesions have a wavy or snake-like border, which matches the description provided by the nurse. This term is often used for parasitic infections, such as cutaneous larva migrains, which create a trail-like pattern on the skin.
Correct Answer is C
Explanation
Choice A reason:
Hemodialysis does not typically result in a significant decrease in RBC count. While there can be a minimal loss of red blood cells during the process, it is not the primary focus of the treatment. The main purpose of hemodialysis is to remove waste products and excess fluid from the blood when the kidneys are not functioning properly.
Choice B reason:
Calcium levels may vary during hemodialysis, and the treatment can be adjusted to prevent significant changes in calcium levels. Hemodialysis can remove some calcium from the blood, but it is usually not the most affected value, and calcium can be added to the dialysate solution if necessary.
Choice C reason:
Potassium is one of the primary electrolytes removed during hemodialysis. High levels of potassium, which can be life-threatening, are commonly seen in clients with renal failure. Hemodialysis effectively reduces high potassium levels, which is crucial for preventing complications such as cardiac arrhythmias.
Choice D reason:
Protein levels are not directly targeted by hemodialysis, and significant protein loss is not a usual outcome of the treatment. The dialysis membrane is designed to allow smaller molecules like urea and potassium to pass through while retaining larger molecules like proteins.
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