A nurse is admitting a client to the surgical unit from the PACU following a cholecystectomy. Which of the following assessments is the nurse's priority?
Bowel sounds
Temperature
Surgical dressing
Oxygen saturation
The Correct Answer is D
Choice A reason: Assessing bowel sounds is important for postoperative care, especially after abdominal surgery, but it is not the immediate priority upon admission from the PACU.
Choice B reason: Monitoring temperature is essential to detect signs of infection or other complications, but it is not the immediate priority right after surgery.
Choice C reason: Checking the surgical dressing for bleeding or signs of infection is important, but maintaining adequate oxygen saturation takes precedence immediately post-surgery.
Choice D reason: Oxygen saturation is the priority assessment because it ensures that the patient is receiving adequate oxygenation after surgery. Respiratory complications are common postoperatively, and ensuring proper oxygenation is crucial for patient safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Urinary incontinence is the involuntary leakage of urine and is not specifically associated with the described urine characteristics of dark amber, cloudiness, and unpleasant odor. These symptoms indicate an infection rather than a condition involving control over urination.
Choice B reason: Urinary retention involves the inability to completely empty the bladder, leading to retained urine. It does not typically manifest with dark amber, cloudy urine, and unpleasant odor, which are more indicative of an infection.
Choice C reason: Urinary frequency refers to the need to urinate more often than usual and does not specifically align with the described urine characteristics. The focus in this case is on the urine's appearance and smell, pointing more towards an infection.
Choice D reason: Urinary tract infection (UTI) is the most likely condition associated with dark amber, cloudy urine, and unpleasant odor. UTIs result from bacterial infection, leading to inflammation and the presence of pus or blood, which causes the described symptoms. Prompt diagnosis and treatment are necessary to prevent complications.
Correct Answer is C
Explanation
Choice A reason: The use of a colostomy bag is expected following surgery for colorectal cancer that involves the creation of a stoma. This does not indicate a complication.
Choice B reason: A loss of appetite is common after major surgery and can be managed with nutritional support and gradual reintroduction of food.
Choice C reason: Absent bowel sounds in the lower abdominal quadrants could indicate a paralytic ileus or bowel obstruction, which are serious complications requiring immediate intervention to prevent further issues such as bowel ischemia.
Choice D reason: Mild pain at the surgical site is expected and can be managed with prescribed pain medications. It does not indicate a serious complication.
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.