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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Using an antibiotic ointment is not typically recommended as a preventive measure for skin integrity during radiation therapy. Antibiotic ointments are used to treat bacterial infections, and their use should be directed by a healthcare provider if an infection is present or there is skin breakdown.
Choice B reason:
It is important not to apply heat to the area of irradiation as heat can increase skin irritation and the risk of burns in the treated area. Patients undergoing radiation therapy are advised to avoid heat sources, including heating pads, hot water bottles, and direct sunlight, to prevent further damage to the skin.
Choice C reason:
Lubricating the skin with hypoallergenic lotion can help maintain skin integrity by keeping it moisturized. However, it is crucial to use lotions that are free of metals, alcohol, perfumes, and dyes, as these can react with radiation and cause skin irritation. Lotions should be applied after radiation therapy sessions and not immediately before treatment.
Choice D reason:
The instruction not to wash the area of irradiation is incorrect. It is essential to keep the skin clean to reduce the risk of infection. Patients should gently wash the irradiated area with lukewarm water and mild soap, and pat the area dry with a soft towel. They should avoid scrubbing or using harsh soaps that can irritate the skin.
Correct Answer is B
Explanation
Choice A reason:
Venous insufficiency can contribute to the development of chronic wounds, particularly in the lower extremities. It is characterized by the inability of the veins to adequately return blood from the legs back to the heart, which can lead to pooling of blood and increased pressure in the veins. This can cause skin changes and ulcers, particularly around the ankles.
Choice B reason:
Malnutrition is indeed a systemic cause of chronic wounds. Adequate nutrition is essential for wound healing, as it provides the necessary proteins, vitamins, and minerals that play a crucial role in the repair process. Protein-energy malnutrition, deficiencies in vitamins C and D, zinc, and other nutrients can impair wound healing and lead to chronic wounds.
Choice C reason:
Infection is typically a local rather than a systemic cause of chronic wounds. While systemic infections can affect wound healing, local wound infections are more directly responsible for delayed healing and the chronicity of wounds. Bacteria can colonize the wound and impede the healing process, leading to a chronic wound.
Choice D reason:
Continued pressure, much like infection, is generally a local cause of chronic wounds. It is most commonly associated with the development of pressure ulcers in individuals who are bedridden or have limited mobility. The constant pressure on certain areas of the body can lead to tissue ischemia and necrosis, resulting in a chronic wound.
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