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 D
Explanation
Cleanse from the innermost point outwards with a circular movement. This technique reduces the risk of contaminating the wound with bacteria from the surrounding skin.
Some possible explanations for the other choices are:
Choice A is wrong because hydrogen peroxide and betadine solution can damage healthy tissue and delay wound healing.
Choice B is wrong because cleansing the wound from the outer edges towards the center can introduce bacteria from the skin into the wound.
Choice C is wrong because using 4x4 gauze to the wound and surrounding skin three times can cause trauma and bleeding to the wound.
Normal ranges for pressure ulcer stages are:
- Stage I: A reddened, painful area on the skin that does not turn white when pressed.
- Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated.
- Stage III: The skin develops an open, sunken hole called a crater or ulcer. The tissue below the skin is damaged.
- Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints.
Correct Answer is D
Explanation
30 to 40 mL/hour. This is the normal range of urine output for a typical adult client. The urine output should be at least 0.5 mL/kg/hour for adults.
Assuming an average weight of 70 kg, this would be 35 mL/hour.
Choice A is wrong because 5 to 10 mL/hour is too low and indicates oliguria, which is a sign of inadequate kidney function or dehydration.
Choice B is wrong because 12 to 15 mL/hour is also below the normal range and may indicate oliguria.
Choice C is wrong because 16 to 25 mL/hour is slightly below the normal range and may indicate reduced kidney perfusion or fluid intake.
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