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:
It is important to keep a Plaster of Paris cast dry because moisture can weaken the cast and irritate the skin underneath. Therefore, the cast should be covered while showering to prevent it from getting wet.
Choice B reason:
Applying ice to the foot after walking can help reduce swelling and provide pain relief. It is a common recommendation for managing discomfort associated with a walking cast. The ice should be applied over the cast at the level of the injury for 15-30 minutes, repeating every few hours for the first few days.
Choice C reason:
While a musty odor can develop over time due to sweat and lack of air circulation, it is not necessarily normal and could indicate a problem such as an infection. If there is a persistent unpleasant odor, it should be evaluated by a healthcare provider.
Choice D reason:
Numbness or pain in the toes can be a sign of compromised circulation or nerve compression and should be reported immediately. It is crucial to monitor for any changes in sensation or increased pain, as these could indicate a serious issue that requires medical attention.
Correct Answer is A
Explanation
Choice A reason:
In the case of burns to the face and chest, assessing for inhalation injuries is critical due to the potential for airway compromise. Inhalation injuries can lead to significant respiratory distress and are considered a high priority in burn care. Inspecting the mouth for soot, burns, or edema can provide immediate information about the potential for respiratory complications, which can be life-threatening.
Choice B reason:
While monitoring urine output is important in burn patients for assessing fluid balance and kidney function, it is not the immediate priority. The insertion of an indwelling urinary catheter can be performed after stabilizing the airway and ensuring the patient is breathing adequately.
Choice C reason:
A CBC count is important for evaluating the patient's overall health status and can indicate the presence of infection or anemia. However, it is not the first action to take in the emergency setting where immediate life-saving interventions are prioritized.
Choice D reason:
Administering intravenous pain medication is important for patient comfort and can facilitate further care, but it is not the first priority. The initial focus should be on life-saving measures such as securing the airway and assessing for inhalation injuries.
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