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 D

Explanation

Choice A reason: Positive Trousseau's sign
Trousseau's sign is indicative of hypocalcemia, not CTS. It is elicited by inflating a blood pressure cuff on the upper arm to above systolic pressure for 3 minutes. A positive sign is characterized by carpal spasm, which is not related to CTS.

Choice B reason: Cool extremities
Cool extremities can be a result of various conditions, including peripheral vascular disease or hypothyroidism. They are not a specific indicator of CTS, which primarily affects nerve function rather than blood circulation or temperature regulation.

Choice C reason: Decreased radial pulse
A decreased radial pulse is not typically associated with CTS. It may indicate a cardiovascular issue or a blockage in the radial artery, which would require further investigation unrelated to CTS.

Choice D reason: Positive Phalen's sign
Phalen's sign is a diagnostic test for CTS. The test is performed by having the patient flex their wrist maximally and hold the position for about 60 seconds. A positive Phalen's sign, which includes numbness and tingling in the thumb, index finger, middle finger, and the radial half of the ring finger, is indicative of CTS. This occurs due to increased pressure on the median nerve when the wrist is in flexion.

A. BUN 8 mg/dL and creatinine 0.7 mg/dL B. BUN 45 mg/dL and creatinine 8 mg/dL C. BUN 23 mg/dL and creatinine 1.0 mg/dL D. BUN 10 mg/dL and creatinine 0.3 mg/dL

Correct Answer is B

Explanation

Choice A reason:
A BUN level of 8 mg/dL and a creatinine level of 0.7 mg/dL are within normal ranges for a healthy individual without kidney disease. In chronic kidney disease (CKD), we would expect these values to be elevated due to the kidneys' reduced ability to filter waste products from the blood.

Choice B reason:
A BUN level of 45 mg/dL and a creatinine level of 8 mg/dL are significantly higher than the normal range, which is consistent with impaired kidney function seen in CKD. These elevated levels indicate that the kidneys are not effectively filtering urea and creatinine from the blood, leading to their accumulation.

Choice C reason:
A BUN level of 23 mg/dL and a creatinine level of 1.0 mg/dL could be seen in the early stages of CKD. While the creatinine level is within the normal range, the BUN level is slightly elevated, which may suggest a decline in kidney function.

Choice D reason:
A BUN level of 10 mg/dL and a creatinine level of 0.3 mg/dL are both below the normal range. This is an unlikely finding for a patient with CKD, as kidney impairment typically leads to increased levels of these substances in the blood.

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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

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