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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A sigmoid colostomy is typically located in the left lower abdomen. This statement accurately informs the client about the expected location of their stoma.
Choice B reason: A colostomy in the sigmoid colon produces formed stool. This area of the colon is responsible for the final stages of digestion where stool becomes more solid.
Choice C reason: The stoma should be pink to red and moist, indicating healthy tissue. A purple color may indicate compromised blood flow and requires immediate medical attention.
Choice D reason: The stoma itself is not typically painful after surgery, although the area around the surgical site may be tender. Pain management focuses on the overall surgical area rather than the stoma itself.
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.
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