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 ["A","B","C","E"]

Explanation

The correct answer is: a, b, c, and e.

Choice A: “I will make sure to feel for changes in my underarm area.”

Reason: This statement is correct because the underarm area (axilla) contains lymph nodes that can be affected by breast cancer. Including the underarm area in a breast self-exam helps in detecting any unusual lumps or changes that could indicate a problem.

Choice B: “It is important to press firmly when feeling my breasts to detect changes.”

Reason: This statement is correct because using firm pressure during a breast self-exam helps to feel the deeper tissues of the breast, which is essential for detecting any abnormalities or lumps that might be present.

Choice C: “I don’t have to lie down to check my breasts. I can stand in the shower.”

Reason: This statement is correct because performing a breast self-exam in the shower is a common and effective method. The wet and slippery skin makes it easier to feel for any changes or lumps in the breast tissue.

Choice D: “If I feel a firm ridge in the lower curve of my breasts, I should report this immediately.”

Reason: This statement is incorrect because it is normal to feel a firm ridge in the lower curve of the breast. This ridge is part of the normal breast anatomy and does not necessarily indicate a problem.

Choice E: “Since I no longer have periods, I can perform an examination at any time of the month.”

Reason: This statement is correct because menopausal women do not have menstrual cycles to guide the timing of their breast self-exams. Therefore, they can choose any consistent day each month to perform the exam.

A. Ecchymosis of the surrounding skin B. Acute pain C. Bounding distal pulse D. Increasing edema

Correct Answer is D

Explanation

Choice A reason:
Ecchymosis, or bruising, of the surrounding skin is a common finding associated with fractures due to the trauma to blood vessels in the area. While it can indicate bleeding or injury, ecchymosis itself does not specifically indicate impaired venous return.

Choice B reason:
Acute pain is a typical symptom following a fracture and results from the injury to the bone and surrounding tissues. Pain is an expected finding and does not directly suggest an issue with venous return.

Choice C reason:
A bounding distal pulse may actually suggest increased arterial flow or could be a sign of other conditions such as high blood pressure or fever. It does not indicate impaired venous return, which is typically characterized by a lack of pulse or a very weak pulse.

Choice D reason:
Increasing edema, or swelling, in the affected arm is a sign of impaired venous return. When veins are unable to effectively return blood to the heart, fluid can accumulate in the tissues, leading to edema. In the context of a fracture, this could be due to compression or damage to the veins, which can impede blood flow and result in swelling.

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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?

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