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 C
Explanation
Unilateral swelling on the posterior of the vulva is not a typical symptom of endometrial cancer. While swelling can occur in the genital area due to various conditions, it is not specifically associated with endometrial cancer.
Choice B reason:
Extreme abdominal pain with intercourse, also known as dyspareunia, can be a symptom of many different conditions, including endometriosis and pelvic inflammatory disease, but it is not commonly associated with endometrial cancer. Endometrial cancer symptoms are more related to abnormal uterine bleeding rather than pain during intercourse.
Choice C reason:
Postmenopausal bleeding is a hallmark symptom of endometrial cancer. Any vaginal bleeding that occurs after menopause should be evaluated by a healthcare provider, as it can be an early sign of endometrial cancer.
Choice D reason:
Green, malodorous vaginal discharge can be a sign of an infection, such as bacterial vaginosis, but is not typically a symptom of endometrial cancer. While abnormal discharge can occur with endometrial cancer, it is usually bloody or watery, not green and malodorous.
Correct Answer is C
Explanation
Choice A reason:
Keeping artificial nails trimmed is a recommended practice in healthcare settings to maintain effective hand hygiene. Long nails can harbor bacteria and make it difficult to clean hands thoroughly. However, the CDC does not provide specific guidelines on the length of artificial nails for healthcare workers.
Choice B reason:
When caring for a client with Clostridium difficile, it is recommended to wash hands with soap and water rather than using alcohol-based hand rubs. Alcohol-based hand rubs are not effective against C. difficile spores. Therefore, thorough handwashing with soap and water is necessary to remove spores.
Choice C reason:
Chlorhexidine is an antiseptic agent that provides broad-spectrum antimicrobial activity and is recommended for hand hygiene in certain situations, such as before invasive procedures or for clients who are immunosuppressed. It is effective against a wide range of bacteria, viruses, and fungi, making it a suitable choice for immunocompromised patients to reduce the risk of infection.
Choice D reason:
The use of alcohol-based hand rubs before administering eye drops is not specifically recommended. While hand hygiene is essential before any contact with a patient, there is no particular preference for alcohol-based hand rubs in this context. The primary concern is to ensure that hands are clean to prevent contamination of the eye drops or the patient's eyes.
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