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

Answer and Explanation

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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Correct Answer is C

Explanation

C. Using a raised toilet seat helps maintain the hips above the knees, which is recommended after THA to reduce strain on the hip joint and facilitate safer toileting. Keeping the hips higher than the knees helps prevent excessive flexion of the hip joint, which can strain the surgical site.

A Twisting at the waist places stress on the hip joint and can increase the risk of dislocation, which is a significant concern after THA surgery.

B. This option does not specify the correct procedure for using a walker

D. Heat application, such as using a heating pad, is not recommended for the operative hip after THA. Heat can increase blood flow and inflammation, potentially worsening pain and swelling.

A. Raise the drainage system to the client's chest level. B. Clamp the tubing to check for air leaks. C. Empty the collection chamber. D. Gently squeeze the tubing to remove excess drainage.

Correct Answer is B

Explanation

B. The appropriate action for a nurse to take would be to check for air leaks in the system. This can be done by clamping the tubing momentarily to see if the bubbling stops, which would suggest the presence of a leak.

A The drainage system should always be kept below the level of the chest and should not be raised or emptied unless specifically indicated.

C. Emptying the collection chamber is typically unnecessary unless it is nearing full capacity. Continuous bubbling in the water seal chamber does not indicate that the collection chamber needs immediate emptying.

D. Squeezing the tubing can disrupt the functioning of the drainage system and is not recommended. Drainage should flow passively into the collection chamber without external manipulation.

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A nurse in the PACU is caring for a client. Which of the following assessments is the nurse's priority?

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