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 A

Explanation

Choice A reason: Infection is a common immediate complication after any surgical procedure, including cholecystectomy. The nurse should monitor for signs of infection, such as fever, redness, swelling, or discharge at the surgical site, to ensure prompt intervention and treatment.
Choice B reason: The term "binding" is unclear and not typically used to describe a specific postoperative complication. This choice may be referring to issues such as adhesions or scar tissue, but these are not immediate concerns.
Choice C reason: Bowel obstruction can occur after abdominal surgery, but it is not the most immediate concern following cholecystectomy. It may develop later as a complication but is not the primary focus in the immediate postoperative period.
Choice D reason: Dehydration can be a concern if the patient is not taking in adequate fluids postoperatively, but it is not as immediate a concern as monitoring for infection.

A. Renal function is reestablished. B. Urine output is less than 400 mL per 24 hr. C. BUN and creatinine levels decrease. D. The glomerular filtration rate (GFR) recovers.

Correct Answer is B

Explanation

Choice A reason: Renal function is not reestablished during the oliguric phase of acute kidney injury. This phase is characterized by significantly reduced urine output, indicating ongoing impaired kidney function.
Choice B reason: Urine output of less than 400 mL per 24 hours is a defining feature of the oliguric phase. This reduced output reflects the kidneys' inability to filter and excrete waste products effectively.
Choice C reason: BUN (Blood Urea Nitrogen) and creatinine levels do not decrease during the oliguric phase; they typically increase due to the kidneys' reduced ability to clear these waste products from the blood.
Choice D reason: The glomerular filtration rate (GFR) does not recover during the oliguric phase. This phase is marked by a decreased GFR, indicating poor kidney function.

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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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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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