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
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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Related Questions
Correct Answer is C
Explanation
Choice A reason:
Bradycardia, or a heart rate that is slower than normal, is not a common finding in anemia. Anemia typically results in a compensatory increase in heart rate, known as tachycardia, to maintain adequate oxygen delivery to tissues.
Choice B reason:
Diarrhea is not a direct symptom of anemia. While it can be a postoperative complication due to various reasons, such as medication side effects or infections, it is not a symptom associated with anemia resulting from excess blood loss.
Choice C reason:
Fatigue is a hallmark symptom of anemia, regardless of the cause. When anemia is due to excess blood loss, the body's oxygen-carrying capacity is diminished due to the reduced number of red blood cells. This leads to fatigue, as tissues and organs receive less oxygen than is needed for optimal function.
Choice D reason:
Hypertension is not typically associated with anemia. In fact, anemia can sometimes lead to hypotension, or low blood pressure, because of the reduced volume of red blood cells in the circulatory system.
Correct Answer is B
Explanation
Choice A reason:
While monitoring urinary output is important after surgery to ensure kidney function and that the urinary tract has not been compromised during surgery, it is not the immediate priority. The nurse should ensure that the client is not experiencing postoperative complications such as urinary retention, but this comes after the assessment of vital signs.
Choice B reason:
Oxygen saturation is the priority assessment for a client being admitted from the PACU following an abdominal hysterectomy. Maintaining adequate oxygenation is critical after anesthesia, as respiratory function can be compromised. The nurse must ensure the client's airway is clear and that they are receiving sufficient oxygen to prevent hypoxia and other respiratory complications.
Choice C reason:
Inspecting the abdominal 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:
Pain management is a significant part of postoperative care, and the nurse will need to assess the client's pain level to manage it effectively. However, the immediate priority is to ensure the client's vital signs are stable, which includes oxygen saturation, before addressing pain.
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