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

Answer and Explanation

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.

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Correct Answer is ["B","C"]

Explanation

Choice A reason:
A temperature of 37.2°C (99°F) is slightly elevated but not necessarily indicative of sepsis. A heart rate of 88/min is within normal limits (60-100/min). This client's signs do not strongly suggest sepsis.

Choice B reason:
A heart rate of 132/min and a respiratory rate of 30/min are both elevated, which can be signs of sepsis. Sepsis can cause an increase in heart rate (tachycardia) and respiratory rate (tachypnea) as the body attempts to maintain adequate blood flow and oxygenation during a systemic infection.

Choice C reason:
A decrease in the level of consciousness combined with a heart rate greater than 130/min could indicate sepsis, as confusion or changes in mental status are common symptoms when the body is fighting a severe infection.

Choice D reason:
Bradypnea, or abnormally slow breathing, is not typically associated with sepsis, which more commonly causes rapid breathing. A WBC count of 10,000/mm³ is at the upper limit of the normal range and does not necessarily indicate sepsis without other symptoms.

Choice E reason:
A temperature of 36°C (96.8°F) is on the lower end of the normal body temperature range and does not suggest fever, which is a common sign of sepsis. A respiratory rate of 16/min is within the normal range (12-20/min) and does not indicate sepsis.

A. Nausea and vomiting B. Hyperactive bowel sounds C. Bradycardia D. Increased urinary output

Correct Answer is A

Explanation

Choice A reason:

Nausea and vomiting are common symptoms of peritonitis, which can occur in clients receiving peritoneal dialysis. These symptoms result from the irritation and inflammation of the peritoneum, the membrane lining the abdominal cavity.

Choice B reason:

Hyperactive bowel sounds are not typically associated with peritonitis. In fact, bowel sounds may be diminished or absent due to the inflammatory process and potential ileus associated with peritonitis.

Choice C reason:

Bradycardia, or a slower than normal heart rate, is not a common manifestation of peritonitis. Peritonitis can cause tachycardia, an increased heart rate, as the body responds to inflammation and infection.

Choice D reason:

Increased urinary output is not a manifestation of peritonitis. Peritoneal dialysis involves the peritoneal cavity and not the urinary system directly. Peritonitis may actually lead to decreased urine output if the infection causes systemic effects.

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A nurse is preparing a client for surgery. Which of the following is a priority when completing an assessment preoperatively?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of critically ill clients. Which of the following clients are exhibiting potential manifestations of sepsis? (Select all that apply)

Correct Answer is ["B","C"]

Explanation

A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following manifestations of peritonitis?

Correct Answer is A

Explanation

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