A nurse is caring for client who just returned from the PACU with an IV fluid infusion and an 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 surgical dressing
The client's bowel sounds
The patency of the NG tube
The Correct Answer is D
A. Coping ability
This is important but not a priority immediately post-op.
B. Surgical dressing
Should be assessed, but airway and tube patency are more urgent.
C. Bowel sounds
Not a priority immediately post-op; expected to be decreased due to anesthesia.
D. Patency of NG tube
Ensures gastric decompression, prevents aspiration, and supports post-op recovery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
A. Monitoring volume status
Maintaining adequate fluid balance prevents hypotension and cerebral hypoperfusion, which can worsen ICP.
B. Ensuring proper ventriculostomy transducer levels
Accurate positioning of the transducer at the level of the foramen of Monro (tragus of the ear) ensures valid ICP readings.
C. Managing sedation
Sedation can reduce cerebral metabolism and help control ICP, especially in agitated patients.
D. Completing hourly endotracheal suctioning
Frequent suctioning increases ICP and should only be done as needed with pre-oxygenation.
E. Elevating the head of the bed 15°
The head of the bed should be elevated 30° (not 15°) to promote venous drainage from the brain and reduce ICP.
Correct Answer is C
Explanation
A. Flushing
More common in allergic reactions than circulatory overload.
B. Vomiting
Not typically seen with circulatory overload.
C. Dyspnea
Shortness of breath is a hallmark of fluid overload and pulmonary congestion.
D. Bradycardia
Tachycardia, not bradycardia, is more common in overload situations.
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