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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Damage to cartilage and bone can progressively worsen. This is a characteristic of osteoarthritis. The disease is a degenerative joint disease that results in the loss of cartilage, which cushions the ends of bones in joints. As the disease progresses, the cartilage becomes thinner and may wear away entirely, causing the bones to rub against each other. This can result in pain, stiffness, and loss of joint movement.
Choice B reason:
Organ failure in later stages may occur without treatment. This statement is not typically associated with osteoarthritis. While osteoarthritis can significantly impact a person's quality of life, it does not directly cause organ failure. However, it's important to manage osteoarthritis effectively to maintain overall health and prevent secondary complications.
Choice C reason:
Inflammation will resolve over time. This is not typically true for osteoarthritis. While some people with osteoarthritis may experience periods of reduced symptoms, the underlying disease process does not resolve over time. In fact, osteoarthritis usually worsens over time.
Choice D reason:
There will be periods of flare-ups and remission of symptoms. This is true for many people with osteoarthritis. Symptoms can vary and may become more severe during periods of activity or stress on the joint. Conversely, symptoms may decrease during periods of rest or with effective management strategies.

Correct Answer is A
Explanation
Choice A reason:
A reddened area over the sacrum is a sign of potential pressure ulcer development, which is a common complication of immobility, especially in bedridden or wheelchair-bound individuals. The sacrum is a prominent bony area that bears weight when a person is sitting or lying down, making it susceptible to pressure ulcers if proper preventative measures, such as regular repositioning, are not taken.
Choice B reason:
Difficulty hearing some types of sounds is not typically a direct complication of immobility. Hearing issues may be related to other health conditions or age-related changes but are not caused by the lack of movement associated with post-stroke immobility.
Choice C reason:
Stiffness in the lower extremities can occur due to immobility, as muscles and joints may become tight when not used regularly. However, this is more of a long-term effect and may not be as immediately concerning as pressure ulcer prevention. Regular range-of-motion exercises can help prevent stiffness.
Choice D reason:
Difficulty moving the upper extremities may be a result of the stroke itself rather than a complication of immobility. While maintaining mobility in all limbs is important, the focus of monitoring should be on complications that arise specifically due to immobility, such as pressure ulcers.
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