The following 4 questions pertain to this case study:
The post-surgical unit nurse receives the patient from the PACU. Select four priority assessments the post-surgical unit nurse should complete.
Assess the surgical dressing.
Obtain the vital signs.
Assess the pain level.
Assess the respiratory rate and effort.
Ask the patient if they have a ride home.
Correct Answer : A,B,C,D
Choice A reason:
Assessing the surgical dressing is crucial to monitor for signs of bleeding, infection, or other complications at the surgical site. The nurse should check the dressing for any excessive drainage, unusual color, or odor, which could indicate an infection or other issues. Ensuring the dressing is intact and clean helps in preventing wound contamination and promotes healing. This assessment is vital in the immediate postoperative period to detect any early signs of complications that may require prompt intervention.
Choice B reason:
Obtaining the vital signs is a fundamental assessment that provides critical information about the patient’s overall physiological status. Vital signs include blood pressure, heart rate, respiratory rate, and temperature. These measurements help in identifying any deviations from the normal ranges that could indicate complications such as hypovolemia, infection, or respiratory distress. Regular monitoring of vital signs allows the nurse to detect and respond to any changes in the patient’s condition promptly. Normal ranges for adults are typically: blood pressure 120/80 mmHg, heart rate 60-100 beats per minute, respiratory rate 12-20 breaths per minute, and temperature around 98.6°F (37°C).
Choice C reason:
Assessing the pain level is essential for effective pain management and patient comfort. Postoperative pain can significantly impact a patient’s recovery and ability to participate in necessary activities such as deep breathing and ambulation. The nurse should use a standardized pain assessment tool, such as the Numeric Rating Scale (0-10), to evaluate the patient’s pain intensity and quality. Effective pain management involves administering prescribed analgesics and evaluating their effectiveness, as well as implementing non-pharmacological interventions as needed. Proper pain control helps in reducing stress, promoting healing, and improving the overall recovery experience.
Choice D reason:
Assessing the respiratory rate and effort is critical to ensure that the patient is breathing adequately and not experiencing respiratory distress. Anesthesia and surgery can affect respiratory function, making it essential to monitor for signs of hypoxia, such as increased respiratory rate, use of accessory muscles, or cyanosis. The nurse should observe the patient’s breathing pattern, listen to breath sounds, and measure oxygen saturation levels using a pulse oximeter. Normal oxygen saturation levels are typically between 95-100%. Prompt identification and management of respiratory issues are crucial to prevent complications such as atelectasis and pneumonia.
Choice E reason:
Asking the patient if they have a ride home is not a priority assessment in the immediate postoperative period. While discharge planning is important, the primary focus should be on stabilizing the patient’s physiological status and addressing any immediate postoperative needs. Ensuring the patient has a ride home can be addressed later in the recovery process, once the patient is stable and ready for discharge. The initial assessments should prioritize monitoring for complications and ensuring the patient’s safety and comfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is True
Explanation
Choice A: True
Urinary tract infections (UTIs) are indeed the most common type of healthcare-associated infection (HAI). According to the Centers for Disease Control and Prevention (CDC), UTIs account for more than 30% of infections reported by acute care hospitals. These infections are primarily caused by the use of catheters and other instrumentation of the urinary tract, which can introduce bacteria and lead to infection. The high prevalence of UTIs in healthcare settings underscores the importance of stringent infection control practices to prevent these infections.
Choice B: False
The statement that UTIs are not the most common healthcare-associated infection is incorrect. While other types of HAIs, such as surgical site infections, bloodstream infections, and pneumonia, are also significant, UTIs remain the most frequently reported. The use of urinary catheters is a major risk factor, and efforts to reduce catheter use and improve catheter care are critical in preventing these infections.
Correct Answer is A
Explanation
The correct answer is A. Gather information on the patient’s current medications, including prescription drugs, over-the-counter drugs, herbal supplements, and vitamins. To ensure accuracy, nurses verify the medication list with the patient, family, caregivers, or community pharmacies and document the information in the patient’s EMR.
Choice A: Gather information on the patient’s current medications, including prescription drugs, over-the-counter drugs, herbal supplements, and vitamins. To ensure accuracy, nurses verify the medication list with the patient, family, caregivers, or community pharmacies and document the information in the patient’s EMR.
This choice accurately describes the comprehensive process of medication reconciliation. Nurses play a crucial role in gathering detailed information about all medications a patient is currently taking, including prescription drugs, over-the-counter medications, herbal supplements, and vitamins. This information is then verified with various sources such as the patient, their family, caregivers, or community pharmacies to ensure its accuracy. Finally, the verified information is documented in the patient’s Electronic Medical Record (EMR). This process helps prevent medication errors, ensures continuity of care, and enhances patient safety.
Choice B: Review the patient’s medication list to verify its accuracy and completeness. They also compare the list of current medications with new orders or prescriptions to detect any discrepancies or potential issues.
While this choice describes an important aspect of medication reconciliation, it is not as comprehensive as Choice A. Verifying the accuracy and completeness of the medication list and comparing it with new orders or prescriptions is a critical step in identifying discrepancies or potential issues. However, it does not encompass the initial gathering of information from various sources or the documentation process, which are essential components of medication reconciliation.
Choice C: Review the medication history provided by the patient and make changes in the medications based on the patient’s current health status. They communicate any medication changes to the patient and the healthcare team.
This choice focuses on reviewing the medication history and making changes based on the patient’s current health status. While this is an important aspect of patient care, it does not fully capture the scope of medication reconciliation. Medication reconciliation involves not only reviewing and updating medications but also gathering comprehensive information from multiple sources and ensuring accurate documentation. This choice lacks the emphasis on verification and documentation that is central to the medication reconciliation process.
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