A nurse is admitting a client to the surgical unit from the Post-Anesthesia Care Unit (PACU) following a cholecystectomy. Which of the following assessments is the nurse's priority?

Bowel sounds

Oxygen saturation

Surgical dressing

Temperature

Answer and Explanation

The Correct Answer is B

Choice A reason:
Bowel sounds are an important assessment to determine the return of gastrointestinal function after surgery. However, they are not the immediate priority following a cholecystectomy. The nurse will monitor bowel sounds to assess for ileus or obstruction, but this comes after ensuring that the patient's vital signs are stable.

Choice B reason:
Oxygen saturation is the priority assessment for a client being admitted from the PACU following a cholecystectomy. Ensuring adequate oxygenation is crucial after anesthesia, as respiratory function can be compromised. Monitoring oxygen saturation helps to detect hypoxemia early and prevent respiratory complications.

Choice C reason:
Inspecting the surgical dressing is necessary to check for signs of bleeding or infection at the surgical site. However, this is not the first priority upon admission from the PACU. The nurse will assess the dressing after vital signs and oxygen saturation have been addressed.

Choice D reason:
Temperature is an important vital sign that can indicate infection or other postoperative complications. However, the immediate priority is to ensure the client's airway and breathing are adequate, which includes assessing oxygen saturation before temperature.

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Correct Answer is B

Explanation

Choice A reason:
The statement that the prosthesis will be adjustable depending on what shoe you are wearing is not accurate. Prostheses are custom-made to fit the individual and are not typically adjustable to different shoe types. The fit and alignment of the prosthesis are crucial for comfort and function, and these are not dependent on the footwear.

Choice B reason:
It is true that clients will need to do special exercises in advance of getting their prosthesis. These exercises are designed to strengthen the remaining limb and prepare the body for the use of a prosthesis. They are an essential part of rehabilitation and help ensure the best possible outcome for the client.

Choice C reason:
Clients are not fitted for their prosthesis at the time of surgery. Fitting for a prosthesis typically occurs after the residual limb has sufficiently healed, which can take several weeks. The fitting process involves careful measurement and customization to ensure the prosthesis will be comfortable and functional.

Choice D reason:
While a special dressing is applied postoperatively, its primary purpose is not to cushion the prosthesis. Initially, dressings are used to protect the surgical site, control swelling, and promote healing. The prosthesis is fitted after the residual limb has healed, and at that time, different types of socket liners may be used for cushioning.

A. "I will place my leg under a heat lamp every 3 hours." B. "I will wrap a warm, wet towel around my right calf every 4 hours." C. "I keep a heating pad on the calf of my right leg when I am lying down." D. "I will sit on the side of the tub and soak my right leg two times every day."

Correct Answer is B

Explanation

Choice A reason:
Placing the leg under a heat lamp every 3 hours is not recommended for the treatment of cellulitis. Heat lamps can cause burns and excessive drying of the skin, which may worsen the condition.

Choice B reason:
Wrapping a warm, wet towel around the affected area is a safe and effective way to apply heat therapy for cellulitis. It can help improve blood flow and relieve discomfort without the risk of burns associated with dry heat sources.

Choice C reason:
Using a heating pad directly on the skin, especially when lying down, can increase the risk of burns and is not recommended for treating cellulitis. Heating pads can provide uneven heat and may exacerbate swelling and inflammation.

Choice D reason:
Soaking the leg in water is not typically advised for cellulitis, especially if there are open wounds or breaks in the skin. Immersion in water can introduce new bacteria to the affected area and potentially worsen the infection.

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A nurse is admitting a client to the surgical unit from the Post-Anesthesia Care Unit (PACU) following a cholecystectomy. Which of the following assessments is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching for a client who is preparing for a below-the-knee amputation. Which of the following statements is true regarding the postoperative placement of a prosthesis?

Correct Answer is B

Explanation

A nurse is providing teaching to a client who has a prescription for heat therapy for the treatment of cellulitis of the right lower leg. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is B

Explanation

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