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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Telling a client that they will be at an increased risk of breast cancer due to fibrocystic breast changes would be incorrect. Fibrocystic breast changes are not directly linked to an increased risk of breast cancer. While the presence of complex fibrocystic changes may slightly elevate the risk, fibrocystic breasts themselves are a common and benign condition.
Choice B reason:
It is not accurate to say that the manifestations of fibrocystic breasts often get worse after menopause. In fact, fibrocystic changes are related to hormone levels, and most women experience relief from these symptoms after menopause when hormone levels decline.
Choice C reason:
Stating that menopause won't have any effect on the manifestations is also incorrect. Menopause typically leads to a decrease in hormone levels, which are associated with fibrocystic breast changes. Therefore, most women see an improvement in their symptoms after menopause.
Choice D reason:
The most appropriate response is that the manifestations usually go away after menopause. Fibrocystic breast changes are linked to hormonal fluctuations, and after menopause, when these fluctuations cease, the symptoms of fibrocystic breasts typically resolve.
Correct Answer is A
Explanation
Choice A reason:
The inability to abduct the arm at the shoulder is a classic sign of a rotator cuff injury. The rotator cuff is responsible for stabilizing the shoulder joint and aiding in various movements, including abduction. When there is a tear or significant weakness in the rotator cuff muscles, especially the supraspinatus muscle, the patient may be unable to lift the arm away from the body or may experience pain while doing so.
Choice B reason:
A negative drop arm test would actually indicate that there is no rotator cuff injury. The drop arm test is performed by asking the patient to fully abduct the arm to 90 degrees and then slowly lower it. If the patient can control the motion and lower the arm smoothly, the test is negative. A positive drop arm test, where the patient cannot control the descent of the arm, would suggest a rotator cuff tear.
Choice C reason:
While an alteration in the contour of the joint may indicate some form of shoulder pathology, it is not specific to a rotator cuff injury. Changes in the contour could be due to various conditions, including dislocation, arthritis, or other musculoskeletal disorders.
Choice D reason:
A positive Tinel's sign is used to diagnose nerve compression or nerve damage, not rotator cuff injuries. It is performed by tapping over the course of a nerve to elicit a tingling sensation or pain in the distribution of the nerve. This sign is commonly associated with conditions like carpal tunnel syndrome.
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