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 C

Explanation

Choice A reason:
Assessing the coping ability of the client is important, but it is not the immediate priority following abdominal surgery. The nurse must first ensure that the client's physiological needs are met and that there are no immediate postoperative complications.

Choice B reason:
While monitoring bowel sounds can provide valuable information about the return of gastrointestinal function, it is not the most immediate concern postoperatively. The nurse should prioritize assessments that ensure the client's safety and immediate physiological stability.

Choice C reason:
Ensuring the patency of the NG tube is the priority assessment. A patent NG tube is crucial for decompressing the stomach, preventing nausea and vomiting, and reducing the risk of aspiration, which can be life-threatening. It is also essential for the removal of gastric secretions and to prevent abdominal distention, which can compromise the surgical site and lead to complications such as wound dehiscence.

Choice D reason:
Assessing the surgical dressing is important to check for signs of bleeding or infection. However, the patency of the NG tube takes precedence as it is directly related to the client's airway and breathing, which are always the top priorities in postoperative care.

A. To determine understanding of the procedure B. To establish the need for psychological support C. To identify possible surgical risks D. To recognize resources needed postoperatively

Correct Answer is C

Explanation

Choice A reason:
Determining the client's understanding of the procedure is important as it ensures informed consent and can help alleviate anxiety. However, while this is a necessary part of preoperative care, it may not be the immediate priority¹.

Choice B reason:
Establishing the need for psychological support is a valuable aspect of holistic care. It addresses the client's emotional well-being and can improve overall satisfaction with the surgical experience. Nonetheless, it is not the primary focus of the preoperative assessment².

Choice C reason:
Identifying possible surgical risks is the priority in a preoperative assessment. This includes evaluating the client's medical history, current health status, and any factors that could increase the risk of complications during or after surgery. A thorough risk assessment is crucial for planning safe surgical care and for making decisions about proceeding with the surgery¹³.

Choice D reason:
Recognizing resources needed postoperatively is part of discharge planning and is essential for ensuring continuity of care. While it is an important consideration, it is not the immediate priority during the preoperative assessment².

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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 caring for a client who has just returned from the Post-Anesthesia Care Unit (PACU) with an intravenous (IV) fluid infusion and a nasogastric (NG) tube in place following abdominal surgery. Which of the following data is the priority for the nurse to assess?

Correct Answer is C

Explanation

A nurse is preparing a client for surgery. Which of the following is a priority when completing an assessment preoperatively?

Correct Answer is C

Explanation

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