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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Unilateral swelling on the posterior of the vulva is not a typical symptom of endometrial cancer. While swelling can occur in the genital area due to various conditions, it is not specifically associated with endometrial cancer.
Choice B reason:
Extreme abdominal pain with intercourse, also known as dyspareunia, can be a symptom of many different conditions, including endometriosis and pelvic inflammatory disease, but it is not commonly associated with endometrial cancer. Endometrial cancer symptoms are more related to abnormal uterine bleeding rather than pain during intercourse.
Choice C reason:
Postmenopausal bleeding is a hallmark symptom of endometrial cancer. Any vaginal bleeding that occurs after menopause should be evaluated by a healthcare provider, as it can be an early sign of endometrial cancer.
Choice D reason:
Green, malodorous vaginal discharge can be a sign of an infection, such as bacterial vaginosis, but is not typically a symptom of endometrial cancer. While abnormal discharge can occur with endometrial cancer, it is usually bloody or watery, not green and malodorous.
Correct Answer is ["A","B","E"]
Explanation
Choice A reason:
Instructing the client to eat cooked foods only is a necessary precaution for immunosuppressed individuals. Cooking foods thoroughly can help eliminate harmful bacteria and other pathogens that could cause infection in a person with a weakened immune system.
Choice B reason:
Restricting visitors who have active infections is crucial in preventing the transmission of potentially harmful pathogens to the immunosuppressed client. Even minor infections in healthy individuals can be severe for someone with a compromised immune system.
Choice C reason:
Disposing of all linen in the trash after use is not a standard precaution for immunosuppressed clients. Used linens should be handled according to the healthcare facility's infection control policies, which often include laundering and not simply discarding in the trash.
Choice D reason:
Limiting the client from bathing daily is not a necessary precaution for immunosuppression. Maintaining good personal hygiene is important, and there is no need to restrict regular bathing unless there is a specific contraindication.
Choice E reason:
Donning a mask, gloves, and gown when caring for an immunosuppressed client can be part of standard precautions, especially if the client is in a protective environment or if the nurse is performing a procedure that has a high risk of contact with bodily fluids or if the client has a known infection.
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