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.
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Related Questions
Correct Answer is B
Explanation
Choice A reason:
Asking about the identity of the assailant, while important for legal purposes, does not contribute to the immediate medical care of the client. The priority is to address potential health issues, such as exposure to HIV.
Choice B reason:
The timing of the assault is critical because it determines the eligibility for PEP. PEP should be initiated as soon as possible, ideally within 2 hours, but it can be effective up to 72 hours after exposure. Knowing the exact time of the assault helps healthcare providers act swiftly to mitigate the risk of HIV transmission.
Choice C reason:
While knowing where the assault occurred can provide context and may be relevant for legal proceedings, it does not influence the immediate medical treatment plan for potential HIV exposure.
Choice D reason:
Consent to involve law enforcement is a separate issue from medical treatment. While it's important to respect the client's wishes regarding reporting, it does not impact the decision-making process regarding HIV prophylaxis.
Correct Answer is C
Explanation
Choice A reason:
Clay-colored stools are typically associated with issues in the biliary system, such as bile duct obstruction or liver infections, and not directly with aspirin use. Aspirin does not typically cause a change in stool color unless there is gastrointestinal bleeding, which would more likely result in black, tarry stools.
Choice B reason:
Nystagmus, which is a vision condition characterized by repetitive, uncontrolled eye movements, is not a known side effect of aspirin. This condition is more commonly associated with neurological disorders, certain medications, or alcohol intoxication.
Choice C reason:
Tinnitus, or ringing in the ears, is a recognized adverse effect of aspirin, especially when taken in high doses or for a prolonged period. It occurs due to aspirin's effect on the inner ear's cochlear cells and can be a sign of salicylate toxicity.
Choice D reason:
Respiratory depression is not a typical side effect of aspirin. Aspirin can cause respiratory alkalosis in cases of overdose, but it does not depress respiration. Instead, it may cause hyperventilation due to stimulation of the respiratory center in the brain.
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