A nurse is caring for a client who has just returned from the Post-Anesthesia Care Unit (PACU) with an intravenous (IV) fluid infusion and a nasogastric (NG) tube in place following abdominal surgery. Which of the following data is the priority for the nurse to assess?
The coping ability of the client
The client's bowel sounds
The patency of the NG tube
The surgical dressing
None
None
The Correct Answer is C
Choice A reason:
Assessing the coping ability of the client is important, but it is not the immediate priority following abdominal surgery. The nurse must first ensure that the client's physiological needs are met and that there are no immediate postoperative complications.
Choice B reason:
While monitoring bowel sounds can provide valuable information about the return of gastrointestinal function, it is not the most immediate concern postoperatively. The nurse should prioritize assessments that ensure the client's safety and immediate physiological stability.
Choice C reason:
Ensuring the patency of the NG tube is the priority assessment. A patent NG tube is crucial for decompressing the stomach, preventing nausea and vomiting, and reducing the risk of aspiration, which can be life-threatening. It is also essential for the removal of gastric secretions and to prevent abdominal distention, which can compromise the surgical site and lead to complications such as wound dehiscence.
Choice D reason:
Assessing the surgical dressing is important to check for signs of bleeding or infection. However, the patency of the NG tube takes precedence as it is directly related to the client's airway and breathing, which are always the top priorities in postoperative care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A reason:
Polyuria, or excessive urination, is not typically a direct complication of a cervical spinal cord injury. Polyuria can be related to other conditions such as diabetes or the use of diuretics.
Choice B reason:
A weakened gag reflex can be a complication of a cervical spinal cord injury, especially if the injury affects the nerves that supply the muscles involved in swallowing. This can increase the risk of aspiration and requires careful monitoring.
Choice C reason:
Hypotension, or low blood pressure, is a common complication following a spinal cord injury due to the disruption of the autonomic pathways that control blood pressure. This condition, known as neurogenic shock, can occur in the acute phase following the injury.
Choice D reason:
Hyperthermia, or elevated body temperature, is not a common direct complication of a cervical spinal cord injury. However, the injury can disrupt temperature regulation, leading to difficulty in either staying warm or cooling down, depending on the environment and level of injury.
Choice E reason:
An absence of bowel sounds can indicate a complication of a cervical spinal cord injury, as the injury may disrupt the normal functioning of the bowel. This can lead to ileus or bowel obstruction, which requires prompt medical attention.
Correct Answer is B
Explanation
Choice A reason:
Malignant melanoma typically presents as a mole that changes in color, size, or feel and has irregular edges. It may also itch, ooze, or bleed. A raised, flesh-colored lesion with pearly white borders is not characteristic of malignant melanoma.
Choice B reason:
Basal cell carcinoma often appears as a raised, pearly bump, sometimes with visible blood vessels, which may have a central depression. The description of the lesion as raised, flesh-colored with pearly white borders aligns with the common presentation of basal cell carcinoma.
Choice C reason:
Squamous cell carcinoma usually presents as a firm, red nodule, or a flat lesion with a scaly, crusted surface. The lesion described does not match the typical appearance of squamous cell carcinoma.
Choice D reason:
Actinic keratosis is characterized by rough, scaly patches on sun-exposed areas of the skin, which may be precancerous. They are not typically described as raised, flesh-colored lesions with pearly borders.
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