A nurse is preparing a client for surgery. Which of the following is a priority when completing an assessment preoperatively?
To determine understanding of the procedure
To establish the need for psychological support
To identify possible surgical risks
To recognize resources needed postoperatively
The Correct Answer is C
Choice A reason:
Determining the client's understanding of the procedure is important as it ensures informed consent and can help alleviate anxiety. However, while this is a necessary part of preoperative care, it may not be the immediate priority¹.
Choice B reason:
Establishing the need for psychological support is a valuable aspect of holistic care. It addresses the client's emotional well-being and can improve overall satisfaction with the surgical experience. Nonetheless, it is not the primary focus of the preoperative assessment².
Choice C reason:
Identifying possible surgical risks is the priority in a preoperative assessment. This includes evaluating the client's medical history, current health status, and any factors that could increase the risk of complications during or after surgery. A thorough risk assessment is crucial for planning safe surgical care and for making decisions about proceeding with the surgery¹³.
Choice D reason:
Recognizing resources needed postoperatively is part of discharge planning and is essential for ensuring continuity of care. While it is an important consideration, it is not the immediate priority during the preoperative assessment².
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
The correct answer is: a. Temperature, c. Color, d. Sensation.
Choice A: Temperature
Reason: Monitoring the temperature of the affected extremity is crucial in evaluating neurovascular status. A cool or cold extremity can indicate decreased perfusion, which may be a sign of neurovascular compromise. Normal skin temperature should be warm to the touch, indicating adequate blood flow.
Choice B: Ecchymosis
Reason: Ecchymosis, or bruising, is not a direct indicator of neurovascular status. While it can provide information about trauma or bleeding, it does not assess the functionality of nerves or blood vessels in the affected extremity.
Choice C: Color
Reason: Assessing the color of the extremity is essential. Pallor or cyanosis can indicate poor blood flow or oxygenation, which are critical signs of neurovascular impairment. Normal color should be consistent with the rest of the body, indicating good circulation.
Choice D: Sensation
Reason: Evaluating sensation helps determine if there is any nerve damage or impairment. Changes in sensation, such as numbness or tingling, can indicate neurovascular compromise. Normal sensation should be intact and symmetrical with the unaffected extremity.
Choice E: Skin Integrity
Reason: While skin integrity is important for overall wound healing and infection prevention, it is not a primary parameter for assessing neurovascular status. It does not provide direct information about blood flow or nerve function.
Correct Answer is B
Explanation
Choice A reason:
Urine specific gravity is a measure of urine concentration. The normal range is typically from 1.005 to 1.030. A specific gravity of 1.035 indicates very concentrated urine, which could be due to dehydration or other factors, but it is not specifically indicative of chronic glomerulonephritis.
Choice B reason:
Serum creatinine is a waste product from the normal breakdown of muscle tissue. Normal levels are approximately 0.6 to 1.2 mg/dL for males. A level of 7 mg/dL is significantly elevated and can indicate severe kidney dysfunction, which is consistent with chronic glomerulonephritis. This condition can lead to a decreased ability of the kidneys to filter waste, causing an accumulation of creatinine in the blood.
Choice C reason:
Creatinine clearance is a test that measures how well creatinine is removed from the blood by the kidneys. The normal range is about 95 to 120 mL/min. A clearance of 120 mL/min is within the normal range and would not typically be expected in a client with chronic glomerulonephritis, as this condition usually results in reduced kidney function.
Choice D reason:
Blood urea nitrogen (BUN) is another waste product filtered by the kidneys. Normal BUN levels are between 7 and 20 mg/dL. A BUN of 15 mg/dL is within the normal range and does not necessarily indicate kidney dysfunction from chronic glomerulonephritis.
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