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

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason:
Purulent drainage at the intravenous site access site would indicate a more severe infection, possibly grade 3 or 4 on the Infusion Nurses Society's phlebitis scale. This would be associated with more advanced symptoms such as pus formation, which is not characteristic of grade 1 phlebitis.

Choice B reason:
Redness at the intravenous access site with pain is indicative of grade 1 phlebitis according to the Infusion Nurses Society's phlebitis scale. This grade is characterized by erythema and possible pain at the site of the IV insertion, without more severe symptoms such as swelling or streak formation.

Choice C reason:
Red streaks on the affected extremity suggest a progression of the inflammatory response, potentially indicating a higher grade of phlebitis, such as grade 2 or 3. This symptom suggests that the inflammation is spreading along the vein, which is more serious than grade 1 phlebitis.

Choice D reason:
A palpable venous cord in the affected extremity would also suggest a more severe form of phlebitis, likely grade 3. This occurs when a thrombus forms along with inflammation of the vein, leading to a palpable cord-like structure.

A. Clay-colored stools B. Nystagmus C. Tinnitus D. Respiratory depression

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.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is caring for a client who is taking aspirin for arthritis. The nurse should identify which of the following findings as an adverse effect of this medication?

Correct Answer is C

Explanation

A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?

A nurse is reviewing the BUN and creatinine levels of an older adult client who has chronic kidney disease. The nurse should expect which of the following findings?

A nurse is educating coworkers about how to minimize back strain and avoid repeated episodes of low back pain. Which of the following strategies should the nurse include? (Select all that apply.)

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?

A nurse is assessing the reflexes of a client who has an unrepaired femur fracture and has suddenly become stuporous. For which of the following findings should the nurse identify that the client exhibits Babinski's sign?

A nurse is planning to teach a client who is scheduled for an intravenous pyelogram (IVP). Which of the following statements should the nurse include in the teaching?

A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?

A nurse is teaching a client who has fibromyalgia about self-care strategies for managing the disorder. Which of the following information should the nurse include in the teaching?