A client has arrived in the inpatient postoperative unit. What action by the inpatient nurse takes priority?
Ensuring the client is warm.
Participating in hand-off report.
Checking the surgical dressings.
Assessing fluid and blood output.
The Correct Answer is D
Rationale for Choice A: Ensuring the client is warm
While maintaining client warmth is important for comfort and to prevent hypothermia, it is not the immediate priority upon arrival in the postoperative unit. Thermoregulation can be addressed after more urgent assessments have been completed.
Rationale for Choice B: Participating in hand-off report
A thorough hand-off report is essential for continuity of care, but it does not take precedence over assessing the client's immediate physiological status. The nurse can gather information from the report while simultaneously performing essential assessments.
Rationale for Choice C: Checking the surgical dressings
Monitoring surgical dressings is a crucial aspect of postoperative care, but it does not take priority over assessing fluid and blood output. Excessive bleeding or fluid shifts can rapidly compromise the client's hemodynamic stability and require prompt intervention.
Rationale for Choice D: Assessing fluid and blood output
This is the priority action for several reasons:
Monitoring for Hemorrhage: Early detection of excessive bleeding is crucial to prevent hypovolemic shock, a life-threatening complication. Postoperative bleeding can occur internally or externally, and prompt assessment of fluid and blood output allows for timely interventions to control bleeding and maintain hemodynamic stability.
Assessing Fluid Balance: Maintaining fluid balance is essential for optimal organ function and electrolyte balance. Postoperative clients are at risk for fluid imbalances due to blood loss, fluid shifts, and the use of diuretics or IV fluids. Assessing fluid intake and output helps to identify and address fluid imbalances early.
Evaluating Renal Function: Urine output is a key indicator of renal function. Postoperative clients are at risk for acute kidney injury due to factors such as hypotension, blood loss, and nephrotoxic medications. Assessing urine output helps to detect early signs of kidney dysfunction and initiate appropriate interventions.
Guiding Fluid and Blood Product Replacement: The assessment of fluid and blood output provides essential information to guide the administration of fluids and blood products as needed. This ensures that the client's fluid status and oxygen-carrying capacity are maintained within safe parameters.
Therefore, assessing fluid and blood output takes priority as it allows the nurse to identify and address potential life- threatening complications promptly, as well as guide interventions to maintain fluid balance and organ function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale for Choice A:
Arranging for a bedside commode can be helpful for patients who have difficulty ambulating to the bathroom. However, it is not the most effective intervention for preventing falls in an ambulatory and independent patient. In fact, it could potentially increase the risk of falls if the patient attempts to use the commode without assistance or if they become disoriented in the dark.
Research has shown that bedside commodes are associated with an increased risk of falls in hospitalized patients. This is because patients may try to get out of bed to use the commode without assistance, or they may become disoriented in the dark and fall.
Additionally, bedside commodes can be a tripping hazard, especially for patients with impaired mobility.
Rationale for Choice B:
Ensuring the bathroom light is kept on during the night can help to reduce the risk of falls by making it easier for the patient to see. However, it is not the most effective intervention for preventing falls.
Patients may still fall even if the bathroom light is on, especially if they are weak, unsteady, or have impaired vision. Additionally, keeping the bathroom light on all night can disrupt the patient's sleep, which can also increase the risk of falls.
Rationale for Choice C:
Using side rails to keep the patient in bed is not an effective intervention for preventing falls. In fact, it can actually increase the risk of falls by making it more difficult for the patient to get out of bed safely.
Patients may try to climb over the side rails, which can lead to falls.
Additionally, side rails can restrict the patient's movement and make them feel trapped, which can lead to agitation and an increased risk of falls.
Rationale for Choice D:
Implementing a toileting schedule is the most effective intervention for preventing falls in an ambulatory and independent patient. This is because it helps to reduce the patient's need to get out of bed at night to use the bathroom.
When a patient has a scheduled time to toilet, they are less likely to try to get out of bed on their own and risk a fall. Additionally, a toileting schedule can help to prevent incontinence, which can also lead to falls.
Correct Answer is A
Explanation
Choice A rationale:
Tolerance to the opiate medication is developing. This is the most likely explanation for why the client's pain is no longer being controlled by the same dose of medication. Tolerance is a physiological adaptation that occurs with repeated exposure to opioids, leading to a decrease in their effectiveness over time. This means that the client's body is becoming less responsive to the medication, and a higher dose is needed to achieve the same level of pain relief.
Choice B rationale:
There is likely a history of addiction. While it is possible that the client has a history of addiction, this is not the most likely explanation for why the medication is no longer controlling the pain. Addiction is a complex condition that is characterized by compulsive drug seeking and use, despite negative consequences. It is not simply a matter of tolerance developing.
Choice C rationale:
The client is opiate naive. This means that the client has not previously been exposed to opioids. While opiate-naive clients may be more sensitive to the effects of opioids, they are also more likely to experience side effects, such as nausea and vomiting. The fact that the client has been receiving the same dose of medication for 2 days without experiencing side effects suggests that they are not opiate naive.
Choice D rationale:
Physical dependence. Physical dependence is a state of adaptation that occurs with repeated exposure to opioids, leading to withdrawal symptoms if the medication is abruptly stopped. However, physical dependence does not necessarily mean that the medication is no longer effective in controlling pain.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.