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.

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Correct Answer is B

Explanation

Choice A reason:
Using an antibiotic ointment is not typically recommended as a preventive measure for skin integrity during radiation therapy. Antibiotic ointments are used to treat bacterial infections, and their use should be directed by a healthcare provider if an infection is present or there is skin breakdown.

Choice B reason:
It is important not to apply heat to the area of irradiation as heat can increase skin irritation and the risk of burns in the treated area. Patients undergoing radiation therapy are advised to avoid heat sources, including heating pads, hot water bottles, and direct sunlight, to prevent further damage to the skin.

Choice C reason:
Lubricating the skin with hypoallergenic lotion can help maintain skin integrity by keeping it moisturized. However, it is crucial to use lotions that are free of metals, alcohol, perfumes, and dyes, as these can react with radiation and cause skin irritation. Lotions should be applied after radiation therapy sessions and not immediately before treatment.

Choice D reason:
The instruction not to wash the area of irradiation is incorrect. It is essential to keep the skin clean to reduce the risk of infection. Patients should gently wash the irradiated area with lukewarm water and mild soap, and pat the area dry with a soft towel. They should avoid scrubbing or using harsh soaps that can irritate the skin.

A. Gingivitis B. Xerostomia C. Candidiasis D. Halitosis

Correct Answer is C

Explanation

Choice A reason:
Gingivitis, an inflammation of the gums, is not specifically associated with a decreased CD4+ T-cell count. While individuals with HIV/AIDS may have an increased risk for periodontal diseases due to a compromised immune system, gingivitis is not directly linked to the CD4+ T-cell count¹.

Choice B reason:
Xerostomia, or dry mouth, can be a side effect of medications or secondary to other conditions but is not an infectious condition. It is not directly related to a decreased CD4+ T-cell count, although it may be more common in individuals with HIV/AIDS due to various factors, including medication side effects¹.

Choice C reason:
Candidiasis, also known as oral thrush, is a common opportunistic infection in individuals with HIV/AIDS, especially when the CD4+ T-cell count is significantly decreased. It is caused by the fungus Candida and can lead to white patches in the mouth, soreness, and difficulty swallowing.

Choice D reason:
Halitosis, or bad breath, is not an infectious condition and is not directly associated with a decreased CD4+ T-cell count. It can result from various factors, including oral hygiene, diet, or underlying health conditions, but it is not a specific concern related to HIV/AID.

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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

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Explanation

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