A nurse in the PACU is caring for a client. Which of the following assessments is the nurse's priority?
Surgical site
Respiratory Status
Level of consciousness
Pain level
The Correct Answer is B
B. This is often the nurse's top priority in the PACU. Anesthesia can depress respiratory function, leading to hypoventilation or airway obstruction. The nurse assesses respiratory rate, effort, oxygen saturation, and auscultates breath sounds to ensure adequate ventilation. Addressing any respiratory compromise promptly is crucial to prevent hypoxia or respiratory arrest.
A Assessing the surgical site is important to monitor for bleeding, infection, or any other complications related to the procedure. However, immediately after surgery, other assessments take precedence over this unless there is a specific concern like excessive bleeding or signs of infection.
C. Monitoring the client's level of consciousness is vital to detect any signs of neurological complications or delayed emergence from anesthesia. The nurse assesses orientation, responsiveness, and neurological signs to ensure the client is awakening appropriately from anesthesia.
D. Assessing pain is important as clients may experience discomfort after surgery. Pain can also affect respiratory function and overall recovery. However, it is typically assessed after ensuring respiratory status and consciousness are stable, as uncontrolled pain can be managed once immediate physiological concerns are addressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A White rice is low in potassium compared to the other options listed, making it a suitable choice for individuals on a low-potassium diet for CKD.
B. Baked potatoes, particularly with the skin, are high in potassium and should be avoided or consumed in very small portions by individuals with CKD who are on a low-potassium diet.
C. While yogurt provides protein and calcium, it is moderate in potassium content and should be consumed in moderation by those limiting potassium intake.
D. Peanut butter is moderate in potassium content. Two tablespoons of peanut butter contain around 200-250 mg of potassium.
Correct Answer is B
Explanation
B. Photophobia, or sensitivity to light, is a common symptom in clients with meningitis. It occurs due to irritation of the meninges and the optic nerve by the inflammatory process. Clients may avoid bright lights and prefer dimly lit environments to reduce discomfort.
A Bradycardia (slow heart rate) is not typically associated with meningitis. In fact, many clients with meningitis may present with tachycardia (fast heart rate) due to fever, dehydration, and systemic inflammation. Therefore, bradycardia is not an expected finding in meningitis.
C. Petechiae (small red or purple spots) on the chest can occur in bacterial meningitis, particularly in cases caused by Neisseria meningitidis. These petechiae are often seen in clusters and can indicate disseminated intravascular coagulation (DIC), a serious complication associated with meningococcal infection. However, they are less specific
D. Headache is a hallmark symptom of meningitis, typically described as severe and persistent. It is often accompanied by other symptoms such as fever, neck stiffness (nuchal rigidity), photophobia, and altered mental status. Headache in meningitis is usually continuous rather than intermittent.
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