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 A
Explanation
Choice A reason:
Nausea and vomiting are common symptoms of peritonitis, which can occur in clients receiving peritoneal dialysis. These symptoms result from the irritation and inflammation of the peritoneum, the membrane lining the abdominal cavity.
Choice B reason:
Hyperactive bowel sounds are not typically associated with peritonitis. In fact, bowel sounds may be diminished or absent due to the inflammatory process and potential ileus associated with peritonitis.
Choice C reason:
Bradycardia, or a slower than normal heart rate, is not a common manifestation of peritonitis. Peritonitis can cause tachycardia, an increased heart rate, as the body responds to inflammation and infection.
Choice D reason:
Increased urinary output is not a manifestation of peritonitis. Peritoneal dialysis involves the peritoneal cavity and not the urinary system directly. Peritonitis may actually lead to decreased urine output if the infection causes systemic effects.
Correct Answer is D
Explanation
Choice A reason:
The lack of insulin production by the pancreas is related to diabetes mellitus, not Addison's disease. Insulin is a hormone that regulates blood sugar levels, and its deficiency leads to diabetes, not Addison's disease.
Choice B reason:
The overproduction of growth hormone by the pituitary gland leads to conditions such as acromegaly or gigantism, depending on the age at which the hormone levels become elevated. It is not related to Addison's disease, which involves the adrenal glands, not the pituitary gland.
Choice C reason:
The overproduction of parathormone by the parathyroid glands leads to hyperparathyroidism, which can cause a variety of symptoms including bone pain, kidney stones, and abdominal pain. This condition is not related to Addison's disease.
Choice D reason:
Addison's disease is indeed caused by the lack of production of hormones by the adrenal glands, particularly cortisol and aldosterone. Aldosterone helps to maintain blood pressure and the balance of sodium and potassium in the blood. When the adrenal glands do not produce enough aldosterone, it can lead to symptoms such as low blood pressure and salt cravings, which are characteristic of Addison's disease.
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