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.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: Mr. Dominic's pain has been controlled to a manageable level, and although he experienced elevated liver enzymes, there are no acute symptoms requiring immediate intervention. He has been able to sleep, indicating that his current condition is stable.
Choice B reason: Mr. Bradford, although experiencing discomfort and blood-tinged urine, is post-surgical, and his condition is stable with managed output. Ambulating is a positive sign post-surgery, indicating recovery. His condition needs monitoring but is not the most urgent.
Choice C reason: Mr. Jennings, who had a TURBT yesterday, is experiencing bladder spasms and high volume irrigation. The output is almost equivalent to the input, which is a positive sign, but bladder spasms can indicate irritation, infection, or a blockage that needs prompt assessment and intervention to prevent further complications.
Choice D reason: Ms. Griffiths presents a similar case to Mr. Dominic, with controlled pain and elevated liver enzymes. She is stable overnight, and her pain level is low after medication, indicating her condition is currently managed.
Correct Answer is B
Explanation
Choice A reason: Wearing an external collection bag is typically associated with other types of urinary diversions, such as an ileal conduit, not a neobladder.
Choice B reason: A neobladder involves the creation of an internal pouch from a segment of the intestine that stores urine and allows for more natural urination, similar to the function of a natural bladder. This option provides the ability to void through the urethra.
Choice C reason: While some initial incontinence can occur after neobladder surgery, the goal is to eventually have voluntary control over urination with time and practice.
Choice D reason: Having a stoma located in the abdomen is characteristic of an ileal conduit or urostomy, not a neobladder. The neobladder is designed to avoid the need for an external stoma.
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