A nurse is assessing a client who is being admitted from the Post-Anesthesia Care Unit (PACU) following an abdominal hysterectomy. Which of the following assessments is the nurse's priority?
Urinary output
Oxygen saturation
Abdominal dressing
Pain level
The Correct Answer is B
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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Related Questions
Correct Answer is C
Explanation
Choice A reason:
Clay-colored stools are typically associated with issues in the biliary system, such as bile duct obstruction, and not directly with aspirin use. Aspirin, especially when used in high doses, is more commonly associated with gastrointestinal side effects like bleeding, which would likely cause dark or bloody stools rather than clay-colored ones.
Choice B reason:
Nystagmus, which is a vision condition characterized by repetitive, uncontrolled eye movements, is not a recognized side effect of aspirin. While aspirin can have effects on various systems in the body, it does not typically affect the muscles or nerves controlling eye movements.
Choice C reason:
Tinnitus, or ringing in the ears, is a well-documented adverse effect of aspirin, particularly when taken in high doses or for a prolonged period. It is related to the effect of aspirin on the inner ear structures and is usually reversible once the medication is stopped or the dosage is reduced.
Choice D reason:
Respiratory depression is not a typical side effect of aspirin. Aspirin can cause respiratory alkalosis in cases of overdose due to hyperventilation, but it does not cause respiratory depression. If respiratory depression occurs, it would likely be due to a different cause and not the aspirin itself.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A reason: Thyroid stimulating hormone (TSH)
TSH levels can affect sexual function. Both hyperthyroidism and hypothyroidism can lead to ED. Hyperthyroidism can cause premature ejaculation, while hypothyroidism can reduce libido and cause ED. Therefore, assessing thyroid function is important in the evaluation of ED.
Choice B reason: Blood glucose
Diabetes mellitus is a common cause of ED. High blood glucose levels can damage blood vessels and nerves that control erection. Therefore, testing for diabetes with a blood glucose test is a standard part of the ED evaluation.
Choice C reason: Partial thromboplastin time (PTT)
PTT is not typically used to evaluate ED. It measures the time it takes for blood to clot and is usually used to assess bleeding disorders or the effectiveness of blood-thinning medication.
Choice D reason: Testosterone
Low testosterone levels can lead to a decrease in sexual desire and ED. Testosterone replacement therapy may improve the situation if this is the case. Hence, measuring testosterone levels is a critical part of the ED workup.
Choice E reason: Total cholesterol
High cholesterol can lead to atherosclerosis, which can impede blood flow to the penis and cause ED. Therefore, a lipid profile, including total cholesterol, is often checked when evaluating ED.
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