A nurse is receiving a client from the post anesthesia unit after a colon resection. What is the first observation the nurse should perform?
Client’s wound dressing is dry.
Client is awake and oriented.
Client is breathing.
Client’s foley catheter is draining.
The Correct Answer is C
The first observation the nurse should perform for a client who is receiving from the post anesthesia unit after a colon resection is to assess the patency of the airway and respiratory function.
This is because the airway is the most vital for the survival of the client and any compromise can lead to hypoxia and death.
The nurse should then take vital signs, check the wound dressing, and assess the foley catheter drainage.
Choice A is wrong because the client’s wound dressing is not as important as the airway and can be checked later.
Choice B is wrong because the client’s level of consciousness may be affected by the anesthesia and is not a priority over the airway.
Choice D is wrong because the client’s foley catheter drainage is not a critical observation and can be monitored later.
Normal ranges for respiratory rate are 12 to 20 breaths per minute for adults, oxygen saturation is 95% to 100%, and blood pressure is 120/80 mmHg for healthy individuals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
“Since I am taking Clozaril, I will need to have bloodwork performed weekly for six months.” This indicates that the client understands that Clozaril (clozapine) is an antipsychotic medication that can affect the immune system and cause a serious blood disorder called agranulocytosis. The client needs to have regular blood tests to monitor the white blood cell count and prevent infections.
Choice B is wrong because Clozaril can cause urinary retention, not decreased urination. The client should be advised to report any difficulty or pain when urinating.
Choice C is wrong because Clozaril is not a PRN medication. It should be taken regularly as prescribed by the doctor to maintain a therapeutic level and prevent relapse of psychotic symptoms.
Choice D is wrong because Clozaril is not available over the counter or in a generic form. It is a controlled substance that requires a special program and a certified pharmacy to dispense it.
Correct Answer is D
Explanation
30 mL. This is because one ounce is equal to 29.57353 milliliters, so one ounce of an elixir medication is approximately 30 milliliters.
The nurse should instruct the client to take 30 milliliters of the medication during discharge teaching.
Choice A is wrong because 5 milliliters is much less than one ounce. Choice B is wrong because 15 milliliters is half of one ounce.
Choice C is wrong because 25 milliliters is slightly less than one ounce.
The nurse should use a conversion factor or a calculator to convert ounces to milliliters accurately.
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