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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A 40-year-old client who has a blood pressure of 138/98 mm Hg should be referred for immediate treatment. This is because this client has grade 1 hypertension according to the International Society of Hypertension (ISH) guidelines, which define hypertension as a systolic blood pressure (SBP) of 140 mm Hg or higher and/or a diastolic blood pressure (DBP) of 90 mm Hg or higher in the office or clinic. This client also has a high risk of cardiovascular complications due to their age and elevated DBP.

Choice A is wrong because a 20-year-old client who has a blood pressure of 125/60 mm Hg does not have hypertension. This client has normal blood pressure according to the ISH guidelines, which define normal blood pressure as an SBP of less than 130 mm Hg and a DBP of less than 85 mm Hg in the office or clinic. This client also has a low risk of cardiovascular complications due to their age and low DBP.

Choice C is wrong because a 55-year-old client who has a blood pressure of 142/68 mm Hg does not need immediate treatment. This client has grade 1 hypertension according to the ISH guidelines, but their DBP is normal. The ISH guidelines recommend lifestyle interventions for three to six months before medication in patients with grade 1 hypertension and no comorbidities.

This client may have other risk factors that need to be assessed, such as obesity, diabetes, or smoking, but they do not require urgent referral.

Choice D is wrong because a 70-year-old client who has a blood pressure of 150/78 mm Hg does not need immediate treatment. This client has grade 1 hypertension according to the ISH guidelines, but their DBP is normal. The ISH guidelines recommend a target blood pressure of less than 140/90 mm Hg within three months for patients older than 65 years, and after three months reduce the target to less than 130/80 mm Hg.

This client may have other risk factors that need to be assessed, such as chronic kidney disease, heart failure, or atrial fibrillation, but they do not require urgent referral.

A. Maintain trust and avoid behaviors that may increase agitation. B. Order the client to go to their room & alert security. C. Tell the client to sit down or risk isolation and loss of privileges. D. Sedate the client after collecting a lithium level.

Correct Answer is A

Explanation

Maintain trust and avoid behaviors that may increase agitation. This is because the client is likely experiencing a manic episode, which is characterized by increased activity, rapid speech, and decreased need for sleep. The nurse should use a calm and supportive approach, provide a safe and structured environment, and avoid confrontation or criticism.

Choice B is wrong because ordering the client to go to their room and alerting security would escalate the situation and violate the client’s rights.

Choice C is wrong because telling the client to sit down or risk isolation and loss of privileges would be threatening and punitive, which could increase the client’s agitation and anger.

Choice D is wrong because sedating the client after collecting a lithium level would be premature and inappropriate without a physician’s order and without assessing the client’s vital signs, mental status, and medication history. Lithium is a mood stabilizer that can cause toxicity if the level is too high.

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A nurse is receiving a client from the post anesthesia unit after a colon resection. What is the first observation the nurse should perform?

Nursing Test Bank

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