When a patient arrives in the PACU with a surgical dressing, an intravenous infusion, and a urinary catheter, the priority action of the nurse is assessment of:
IV line patency
urine output
airway patency
wound drainage
None
None
The Correct Answer is C
A. IV line patency: IV access is important for fluid and medication administration, but it is not the highest priority immediately postoperatively.
B. Urine output: Monitoring urine output is important for assessing kidney function and fluid balance, but airway management takes precedence.
C. Airway patency: The priority in the immediate postoperative period is maintaining a patent airway, as patients are at risk for respiratory complications such as obstruction, hypoxia, and aspiration due to anesthesia effects.
D. Wound drainage: Assessing wound drainage is necessary to monitor for excessive bleeding or infection, but it is not the top priority compared to airway patency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Alternately compress and release to help blood flow through vessels. Sequential compression devices (SCDs) work by alternating compression and release to promote venous return, prevent stasis, and reduce the risk of deep vein thrombosis (DVT). This is the correct mechanism of action for these devices.
B. Measure pressure in the leg blood vessels and sound an alarm if pressure rises. SCDs do not measure pressure; they are designed to apply intermittent pressure to the legs to encourage circulation and prevent clot formation.
C. Provide gentle continuous compression at low pressure. SCDs apply intermittent pressure, not continuous pressure. Continuous compression would not be effective in preventing DVT as it does not allow for the periodic relaxation of veins.
D. Provide firm continuous compression at high pressure. SCDs should apply intermittent, not continuous, pressure. High pressure could potentially harm the patient’s circulation and tissues, which is why the compression is designed to be gentle and alternating.
Correct Answer is A
Explanation
A. Dehiscence: Dehiscence refers to the partial or total separation of the wound's layers, often occurring after surgery, such as when coughing increases intra-abdominal pressure.
B. Laceration: A laceration refers to a tear or break in the skin due to trauma, not a surgical complication.
C. Evisceration: Evisceration occurs when the internal organs protrude through the wound, which is a more severe complication than dehiscence.
D. Autologous: Autologous refers to using a person's own tissues or cells (e.g., blood transfusion), not a wound complication.
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