A nurse is preparing a client for surgery. Which of the following is a priority when completing an assessment preoperatively?

To determine understanding of the procedure

To establish the need for psychological support

To identify possible surgical risks

To recognize resources needed postoperatively

Answer and Explanation

The Correct Answer is C

Choice A reason:
Determining the client's understanding of the procedure is important as it ensures informed consent and can help alleviate anxiety. However, while this is a necessary part of preoperative care, it may not be the immediate priority¹.

Choice B reason:
Establishing the need for psychological support is a valuable aspect of holistic care. It addresses the client's emotional well-being and can improve overall satisfaction with the surgical experience. Nonetheless, it is not the primary focus of the preoperative assessment².

Choice C reason:
Identifying possible surgical risks is the priority in a preoperative assessment. This includes evaluating the client's medical history, current health status, and any factors that could increase the risk of complications during or after surgery. A thorough risk assessment is crucial for planning safe surgical care and for making decisions about proceeding with the surgery¹³.

Choice D reason:
Recognizing resources needed postoperatively is part of discharge planning and is essential for ensuring continuity of care. While it is an important consideration, it is not the immediate priority during the preoperative assessment².

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Correct Answer is B

Explanation

Choice A reason:
Bowel sounds are an important assessment to determine the return of gastrointestinal function after surgery. However, they are not the immediate priority following a cholecystectomy. The nurse will monitor bowel sounds to assess for ileus or obstruction, but this comes after ensuring that the patient's vital signs are stable.

Choice B reason:
Oxygen saturation is the priority assessment for a client being admitted from the PACU following a cholecystectomy. Ensuring adequate oxygenation is crucial after anesthesia, as respiratory function can be compromised. Monitoring oxygen saturation helps to detect hypoxemia early and prevent respiratory complications.

Choice C reason:
Inspecting the surgical 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:
Temperature is an important vital sign that can indicate infection or other postoperative complications. However, the immediate priority is to ensure the client's airway and breathing are adequate, which includes assessing oxygen saturation before temperature.

A. pH 7.50, HCO₃⁻ 20 mEq/L, PaCO₂ 32 mm Hg B. pH 7.25, HCO₃⁻ 19 mEq/L, PaCO₂ 30 mm Hg C. pH 7.30, HCO₃⁻ 26 mEq/L, PaCO₂ 50 mm Hg D. pH 7.55, HCO₃⁻ 30 mEq/L, PaCO₂ 31 mm Hg

Correct Answer is B

Explanation

Choice A reason:
This choice suggests a pH of 7.50, which is indicative of alkalosis, and not typically expected in a client with chronic kidney disease (CKD). CKD often leads to metabolic acidosis due to the accumulation of acids in the body as the kidneys fail to excrete them. The HCO₃⁻ level of 20 mEq/L is slightly lower than the normal range (22-26 mEq/L), and the PaCO₂ of 32 mm Hg is within the normal range (35-45 mm Hg), but these values do not align with the expected acidosis associated with CKD.

Choice B reason:
This set of values is consistent with metabolic acidosis, which is commonly seen in clients with CKD. A pH of 7.25 indicates acidemia, and an HCO₃⁻ level of 19 mEq/L is below the normal range, suggesting a primary metabolic acidosis. The PaCO₂ of 30 mm Hg is at the lower end of the normal range, which may indicate a compensatory respiratory response to the metabolic acidosis.

Choice C reason:
A pH of 7.30, while on the lower side, is not as acidic as one would expect in a client with CKD. The HCO₃⁻ level of 26 mEq/L is within the normal range, and a PaCO₂ of 50 mm Hg suggests respiratory acidosis, which is not the primary disorder in CKD.

Choice D reason:
This choice indicates a pH of 7.55, which is too alkaline and not characteristic of CKD, where metabolic acidosis is the expected finding. An HCO₃⁻ level of 30 mEq/L is higher than the normal range, suggesting metabolic alkalosis. The PaCO₂ of 31 mm Hg is slightly below the normal range, possibly indicating a compensatory response, but it does not align with the metabolic acidosis typically seen in CKD.

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A nurse is preparing a client for surgery. Which of the following is a priority when completing an assessment preoperatively?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client to the surgical unit from the Post-Anesthesia Care Unit (PACU) following a cholecystectomy. Which of the following assessments is the nurse's priority?

Correct Answer is B

Explanation

A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?

Correct Answer is B

Explanation

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