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. The CPM machine should be used during designated therapy sessions as prescribed by the healthcare provider. Turning it off during meals allows the client to focus on eating without interference from the machine.
A The range of motion settings on the CPM machine should be adjusted gradually according to the client's tolerance and prescribed therapy plan. Rapidly increasing the range of motion could cause discomfort, pain, or even injury to the client's knee joint. Therefore, the nurse should not increase the range of motion rapidly.
B Storing the CPM machine on the floor is not ideal because it can increase the risk of contamination or damage to the equipment. The machine should be stored on a clean, stable surface when not in use to prevent accidental damage or exposure to dirt and debris.
D. Regular checks of the CPM machine's settings are important, but every 12 hours may not be frequent enough to ensure the machine is functioning correctly and safely.
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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