After ensuring a postoperative client has a patent airway, what is the next most important nursing assessment?
Level of consciousness
Condition of drains
Appearance of the surgical dressing
Stability of vital signs
The Correct Answer is D
A. Level of consciousness: While important, it follows the assessment of vital signs to ensure the client's overall stability.
B. Condition of drains: This is relevant but not as immediate as assessing the stability of vital signs.
C. Appearance of the surgical dressing: This is important but secondary to ensuring the client’s vital signs are stable.
D. Stability of vital signs: This is the most critical next assessment after ensuring a patent airway, as vital signs reflect the client's immediate physiological status and stability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B"]
Explanation
B. Temperature 38.6°C (101.4°F): An elevated temperature in the postoperative period may indicate an infection, which requires immediate evaluation and management.
A. Heart rate 72 beats/min: This is within the normal range and does not indicate an urgent issue.
C. Surgical dressing dry and intact: This is a positive finding and does not require immediate attention.
D. Pain rating 3 out of 10: This level of pain is manageable and does not indicate a severe issue.
E. Limited ambulation: Limited ambulation is expected post-surgery and does not necessarily indicate an urgent problem.
Correct Answer is C
Explanation
A. Ask why the client is taking steroid therapy: While understanding the reason for steroid therapy is important, it does not address the immediate need to manage the medication administration.
B. Notify the surgeon immediately: Notifying the surgeon might be necessary if there are specific concerns, but it is not the most immediate action regarding medication administration.
C. Administer an IV equivalent dose of Prednisone: Since the client is NPO, administering an oral medication could be contraindicated. Administering an IV equivalent ensures the client receives the necessary steroid therapy without risking complications from taking oral medication while fasting.
D. Give the oral steroid with a small sip of water: This may not be appropriate due to the NPO status, which typically restricts oral intake.
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