A nurse in the PACU is caring for a client.
Which of the following assessments is the nurse's priority?
Respiratory status.
Surgical site.
Level of consciousness.
Pain level.
The Correct Answer is A
The nurse’s priority assessment in the PACU (Post-Anesthesia Care Unit) should be the client’s respiratory status.
This is because the client is recovering from anesthesia and may have an altered respiratory function.
Choice B, assessing the surgical site, is not an answer because it is not the priority assessment for a client in the PACU.
Choice C, assessing the level of consciousness, is not an answer because it is not the priority assessment for a client in the PACU.
Choice D, assessing the pain level, is not an answer because it is not the priority assessment for a client in the PACU.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A change in behavior such as agitation and restlessness in a client with a traumatic brain injury can be a sign of increased intracranial pressure.
The nurse should first assess the client’s blood pressure as an increase in blood pressure can be an indicator of increased intracranial pressure.
Motor responses are not the first assessment that should be performed.
Blood glucose is not the first assessment that should be performed.
Urinary output is not the first assessment that should be performed.
Correct Answer is B
Explanation
This statement indicates an understanding of the teaching because serum ammonia levels can be elevated in liver disease and are used to monitor the progression of liver disease.
Choice A is incorrect because glucose levels are not typically used to monitor liver disease.
Choice C is incorrect because serum troponin levels are used to diagnose heart attacks, not liver disease.
Choice D is incorrect because phosphate levels are not typically used to monitor liver disease.
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