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.
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Related Questions
Correct Answer is C
Explanation
C. This is crucial because good medication adherence is essential for a transplant recipient to prevent rejection and maintain overall health. Non-adherence can jeopardize the transplant's success.
A This could be a risk factor for the client's own health, but it's not directly related to the transplant process or medication adherence.
B. This highlights a psychosocial concern, important for overall well-being, but doesn't directly impact the transplant candidacy.
D. This might be relevant for the medical history, but it doesn't directly affect medication adherence or the immediate transplant candidacy (unless the asthma is severe and uncontrolled).
Correct Answer is D
Explanation
D. Edema is expected in the initial hours and days following major burns and can be particularly pronounced in full-thickness burns due to extensive tissue damage and inflammation.
A Initially, full-thickness burns may not be as painful due to nerve damage; however, surrounding areas with partial-thickness burns or areas where nerve endings are intact can be extremely painful. The absence of severe pain at the site of full-thickness burns is common initially due to nerve damage, but pain management is crucial as inflammation progresses.
B. Full-thickness burns typically involve destruction of the entire epidermis and dermis, leading to the absence of blisters. Blisters are characteristic of partial-thickness burns, where the epidermis is partially damaged but not completely destroyed.
C. Epithelialization refers to the process of new skin cells migrating and covering the wound, a process that occurs during the later stages of wound healing. In the acute phase of full-thickness burns, epithelialization does not occur because the skin layers are completely destroyed. This process starts later once the wound has been adequately debrided and begins to heal.
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