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 Structured activities are important for clients with Alzheimer's disease because they can help provide a sense of routine, purpose, and control. Engaging the client in meaningful activities that are simple and appropriate for their cognitive level can help prevent boredom, restlessness, and agitation.
B. Keeping the client's room dark during the day is not recommended as it can disrupt the client's sleep- wake cycle. Instead, maintaining a regular sleep schedule, promoting natural light exposure during the day, and ensuring a quiet, calm environment at night are more effective strategies.
C. While displaying a calendar can be helpful for some individuals with Alzheimer's, it doesn't directly address the need for structured activities or engagement throughout the day.
D. Providing excessive stimulation can overwhelm individuals with Alzheimer's disease. It's important to create a calm, predictable environment with familiar objects and routines to minimize confusion and agitation.
Correct Answer is C
Explanation
C. Restlessness and agitation can be early signs of increased ICP. They result from the brain's attempt to compensate for the increasing pressure. Restlessness may indicate discomfort or confusion caused by cerebral edema or pressure on brain structures.
A Projectile vomiting can occur with increased ICP due to stimulation of the vomiting center in the brainstem as a response to pressure on the brain. It is a symptom that may indicate a more advanced increase in ICP rather than an early manifestation.
B. Papilledema refers to swelling of the optic disc due to increased intracranial pressure transmitting through the optic nerve sheath. It is typically a late manifestation of increased ICP rather than an early one. It requires time for pressure to build up and affect the optic nerve.
D. Decorticate posturing is a type of abnormal posture that can occur with severe brain injury or increased ICP. It involves flexion of the arms, wrists, and fingers with adduction of the upper extremities and extension of the lower extremities. This is typically a later sign of increased ICP
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.