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 B
Explanation
Choice A reason: Hepatitis is inflammation of the liver and does not directly cause biliary sludge. It can lead to liver damage and other complications, but not specifically biliary sludge.
Choice B reason: Bile stasis, or the stagnation of bile, leads to the formation of biliary sludge. When bile does not flow properly, it can thicken and form sludge, which consists of bile salts, cholesterol, and other substances.
Choice C reason: Ascites is the accumulation of fluid in the peritoneal cavity, typically due to liver disease, and does not cause biliary sludge.
Choice D reason: Biliary colic is pain caused by the obstruction of the bile ducts, often by gallstones, but it does not itself cause the formation of biliary sludge. Sludge can lead to biliary colic if it obstructs the bile ducts, but it is not a causative condition.
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.
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