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:
Alendronate is a bisphosphonate, which is commonly prescribed for Paget's disease of the bone. Bisphosphonates help regulate bone growth and can be a lifelong medication for managing this condition. They work by inhibiting osteoclasts, the cells that break down bone tissue, which helps to normalize the bone remodeling process.
Choice B reason:
Colchicine is used to treat gout and not typically used for Paget's disease. It works by reducing the inflammation caused by uric acid crystals but does not affect the bone remodeling process that is characteristic of Paget's disease.
Choice C reason:
Allopurinol is also used to treat gout by decreasing uric acid production in the body. Like colchicine, it is not used to treat Paget's disease because it does not address the abnormal bone metabolism associated with the condition.
Choice D reason:
Prednisone is a corticosteroid used to reduce inflammation in various conditions. While it may be used in some cases to manage pain and inflammation associated with Paget's disease, it is not a primary treatment for the disease itself and does not regulate bone growth like bisphosphonates do.
Correct Answer is ["A","B","C","E"]
Explanation
The correct answer is: a, b, c, and e.
Choice A: “I will make sure to feel for changes in my underarm area.”
Reason: This statement is correct because the underarm area (axilla) contains lymph nodes that can be affected by breast cancer. Including the underarm area in a breast self-exam helps in detecting any unusual lumps or changes that could indicate a problem.
Choice B: “It is important to press firmly when feeling my breasts to detect changes.”
Reason: This statement is correct because using firm pressure during a breast self-exam helps to feel the deeper tissues of the breast, which is essential for detecting any abnormalities or lumps that might be present.
Choice C: “I don’t have to lie down to check my breasts. I can stand in the shower.”
Reason: This statement is correct because performing a breast self-exam in the shower is a common and effective method. The wet and slippery skin makes it easier to feel for any changes or lumps in the breast tissue.
Choice D: “If I feel a firm ridge in the lower curve of my breasts, I should report this immediately.”
Reason: This statement is incorrect because it is normal to feel a firm ridge in the lower curve of the breast. This ridge is part of the normal breast anatomy and does not necessarily indicate a problem.
Choice E: “Since I no longer have periods, I can perform an examination at any time of the month.”
Reason: This statement is correct because menopausal women do not have menstrual cycles to guide the timing of their breast self-exams. Therefore, they can choose any consistent day each month to perform the exam.
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