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
Insert a sterile needle and aspirate 3 to 5 mL of urine into the syringe. This is the best technique for obtaining a sterile urine specimen from an indwelling urinary catheter because it ensures that microorganisms in the specimen are from the urine, and not the result of contamination.
Choice B is wrong because it does not use sterile technique and it does not collect fresh urine. The urine in the drainage bag may have been sitting there for a long time and may not reflect the current condition of the patient’s urinary tract.
Choice C is wrong because it does not use sterile technique and it flushes the catheter with sterile water, which may dilute the urine and alter its composition.
Choice D is wrong because it does not use sterile technique and it collects urine from the drainage bag, which may be contaminated or stale.
Correct Answer is C
Explanation
Chicken breast, green beans, and a glass of milk. This is because chicken breast is a good source of protein, which is essential for wound healing. Green beans are rich in vitamin C, which helps with collagen synthesis and immune function. Milk is a good source of calcium and vitamin D, which are important for bone health and healing.
Choice A is wrong because cheese pizza and french fries are high in fat and sodium, which can increase inflammation and delay wound healing. Orange juice is high in sugar, which can also impair wound healing and increase the risk of infection.
Choice B is wrong because cheeseburger and potato chips are also high in fat and sodium, and have similar effects as choice A. Soda is also high in sugar and can cause dehydration, which can slow down wound healing.
Choice D is wrong because spaghetti and meatballs are high in refined carbohydrates, which can spike blood sugar levels and impair wound healing.
A roll is also a refined carbohydrate and does not provide much fiber or nutrients. Chocolate pudding is high in sugar and fat, and can also worsen wound healing.
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