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

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A reason: A bladder infection can cause various symptoms, but blood-tinged urine is less specific to it.
Choice B reason: Dehydration typically leads to concentrated urine, not blood-tinged urine.
Choice C reason: Prostate enlargement (benign prostatic hyperplasia) can cause blood-tinged urine due to irritation and pressure on the urethra.
Choice D reason: Pernicious anemia affects red blood cell production but is not directly related to the presence of blood in the urine.

A. Mr. Smith, who has multiple sclerosis, has been managing his urinary retention with intermittent catheterization for several years. He has been depressed lately after losing his job and admitted at his last visit to having thoughts of self-harm. He left a message saying he had chills, fatigue, and an oral temperature of 103°F. B. Ms. Jones, who has had urinary frequency and urgency for many years, started on Ditropan at her last office visit. She left a message saying her urinary frequency has improved, but her mouth was very dry. C. Mr. Jones, a new patient expressing concerns over embarrassing symptoms of incontinence. D. Ms. Smith, who is 18 years old, called to cancel her afternoon appointment for her initial incontinence evaluation. Her message said her symptoms weren't that bad and she would call to reschedule.

Correct Answer is A

Explanation

Choice A reason: Mr. Smith requires immediate attention due to his multiple sclerosis and severe symptoms of chills, fatigue, and a high fever (103°F). These symptoms could indicate a severe infection such as a urinary tract infection (UTI) or even sepsis, which can be life-threatening, especially in individuals with a compromised immune system or chronic conditions like multiple sclerosis.
Choice B reason: Ms. Jones's dry mouth is a common side effect of Ditropan (oxybutynin), which is used to treat urinary frequency and urgency. While it is uncomfortable, it is not an emergency and can be addressed at the next visit or over a phone consultation.
Choice C reason: Mr. Jones, being a new patient with incontinence concerns, does not present an immediate emergency. This issue, while significant for his quality of life, can be managed through a scheduled appointment.
Choice D reason: Ms. Smith's decision to cancel her appointment due to her symptoms not being severe does not require immediate attention. She can be rescheduled for a later date without risk to her health.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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