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 B
Explanation
Choice A reason:
Squamous cell carcinoma typically presents as a rough, scaly, red patch, open sore, or raised growth with a central depression, often on sun-exposed areas of the body. While it can appear as a lesion that varies in color, it is not commonly associated with a nevus that has increased in size.
Choice B reason:
Malignant melanoma is associated with changes in preexisting nevi, such as an increase in size and variations in color. It often appears as a mole that changes in color, size, or feel and may have irregular edges. The description of the lesion provided by the client is characteristic of malignant melanoma, making this the correct diagnosis.
Choice C reason:
Kaposi's sarcoma is a cancer that forms in the lining of blood and lymph vessels and typically appears as patches of abnormal tissue on the skin or mucous membranes. These lesions are usually red or purple and look similar to bruises¹. They are not typically described as nevi that increase in size or lesions that vary in color.
Choice D reason:
Basal cell carcinoma often appears as a slightly transparent bump on the skin, though it can take other forms. It usually presents as a pearly white or pink bump on white skin, or a brown or black bump on darker skin, and is most often found on sun-exposed areas. It is not typically associated with a nevus that has increased in size or an irregularly shaped lesion that varies in color.
Correct Answer is B
Explanation
Choice A reason:
While autoimmune disorders are associated with type 1 diabetes, where the immune system attacks the pancreas, they are not typically a direct risk factor for type 2 diabetes. Type 2 diabetes is more closely related to lifestyle factors and insulin resistance.
Choice B reason:
A 40-year-old client with hypoglycemia may be at risk for developing type 2 diabetes. Hypoglycemia can be a sign of pre-diabetes or insulin resistance, where the body's response to insulin is not as effective, leading to fluctuations in blood sugar levels. As individuals age, their risk for type 2 diabetes increases, particularly if they have other risk factors such as a sedentary lifestyle, overweight, or a family history of diabetes.
Choice C reason:
Lack of sleep can contribute to the development of type 2 diabetes by affecting the body's ability to regulate glucose and by increasing insulin resistance. However, without additional risk factors, it is not as strong a predictor of type 2 diabetes as the presence of hypoglycemia or other metabolic conditions.
Choice D reason:
Having never given birth is not a recognized risk factor for type 2 diabetes. While gestational diabetes is a risk factor for developing type 2 diabetes later in life, the absence of pregnancy does not increase the risk.
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