A nurse is caring for a client who has just returned from the Post-Anesthesia Care Unit (PACU) with an intravenous (IV) fluid infusion and a nasogastric (NG) tube in place following abdominal surgery. Which of the following data is the priority for the nurse to assess?
The coping ability of the client
The client's bowel sounds
The patency of the NG tube
The surgical dressing
None
None
The Correct Answer is C
Choice A reason:
Assessing the coping ability of the client is important, but it is not the immediate priority following abdominal surgery. The nurse must first ensure that the client's physiological needs are met and that there are no immediate postoperative complications.
Choice B reason:
While monitoring bowel sounds can provide valuable information about the return of gastrointestinal function, it is not the most immediate concern postoperatively. The nurse should prioritize assessments that ensure the client's safety and immediate physiological stability.
Choice C reason:
Ensuring the patency of the NG tube is the priority assessment. A patent NG tube is crucial for decompressing the stomach, preventing nausea and vomiting, and reducing the risk of aspiration, which can be life-threatening. It is also essential for the removal of gastric secretions and to prevent abdominal distention, which can compromise the surgical site and lead to complications such as wound dehiscence.
Choice D reason:
Assessing the surgical dressing is important to check for signs of bleeding or infection. However, the patency of the NG tube takes precedence as it is directly related to the client's airway and breathing, which are always the top priorities in postoperative care.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
While gargling with warm saline can provide symptomatic relief for a sore throat, it does not address the underlying bacterial infection. Therefore, it is not the priority action once a diagnosis of group A streptococcus has been confirmed.
Choice B reason:
Identifying close contacts is important for public health tracking and potentially preventing the spread of the infection. However, the immediate priority for the client is the initiation of treatment to address the infection.
Choice C reason:
Taking antipyretics can help manage fever and provide comfort to the client. While managing symptoms is important, it is secondary to initiating antibiotic therapy, which addresses the cause of the symptoms.
Choice D reason:
The priority action is to notify the client to return to the clinic for initiation of antibiotic therapy. Group A streptococcus is a bacterial infection that requires antibiotics for treatment. Prompt initiation of antibiotics is crucial to prevent complications and promote recovery.
Correct Answer is D
Explanation
Choice A reason:
While a blood glucose level of 120 mg/dL is slightly above the normal range, it is not typically considered an emergency for a client with type 2 diabetes mellitus. This client would require monitoring and potential adjustment of their diabetes management plan, but it does not necessitate immediate assessment.
Choice B reason:
For a client with diabetes insipidus, an intake of 1,500 mL and an output of 1,600 mL in 24 hours is within expected parameters, considering the condition's characteristic polyuria and polydipsia. This client would need ongoing monitoring to maintain fluid balance but is not the highest priority for immediate assessment.
Choice C reason:
A heart rate of 100/min and tremors in a client with Graves' disease could indicate that their condition is not well-controlled. However, these symptoms are not as acutely concerning as those of a stroke and would be addressed after more urgent needs are met.
Choice D reason:
A client who has had a left-sided stroke and reports a severe headache and confusion is exhibiting signs of a possible acute neurological change or complication, such as increased intracranial pressure or hemorrhage. This client requires immediate assessment and intervention due to the potential for rapid deterioration and life-threatening complications.
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