A nurse is receiving a client from the post anesthesia unit after a colon resection. What is the first observation the nurse should perform?
Client’s wound dressing is dry.
Client is awake and oriented.
Client is breathing.
Client’s foley catheter is draining.
The Correct Answer is C
The first observation the nurse should perform for a client who is receiving from the post anesthesia unit after a colon resection is to assess the patency of the airway and respiratory function.
This is because the airway is the most vital for the survival of the client and any compromise can lead to hypoxia and death.
The nurse should then take vital signs, check the wound dressing, and assess the foley catheter drainage.
Choice A is wrong because the client’s wound dressing is not as important as the airway and can be checked later.
Choice B is wrong because the client’s level of consciousness may be affected by the anesthesia and is not a priority over the airway.
Choice D is wrong because the client’s foley catheter drainage is not a critical observation and can be monitored later.
Normal ranges for respiratory rate are 12 to 20 breaths per minute for adults, oxygen saturation is 95% to 100%, and blood pressure is 120/80 mmHg for healthy individuals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is because non-steroidal anti-inflammatory drugs (NSAIDs) are medicines that are used to treat rheumatoid arthritis by reducing pain, inflammation, and swelling.
However, NSAIDs do not slow down the disease progression or prevent joint
damage. Therefore, they are often used along with other types of medications, such as methotrexate or biologics, that can modify the disease course. NSAIDs may take up to two weeks to reach their full anti-inflammatory effect.
Choice A is wrong because using aspirin to relieve other types of pain can increase the risk of bleeding and stomach ulcers when taken with NSAIDs.
Choice C is wrong because taking the medication on an empty stomach can increase the risk of stomach irritation and ulcers.
Choice D is wrong because taking the medication after exercising does not prevent the progression of disease or joint damage.
Correct Answer is A
Explanation
Using an automatic BP cuff with a shivering client with a history of an irregular heart rate can result in inaccurate and low readings.
This is because shivering can interfere with the cuff inflation and deflation, and an irregular heart rate can affect the accuracy of the device.
The nurse should intervene and use a manual BP cuff with a stethoscope instead.
Choice B is wrong because pulling the client’s ear pinna backward, up and out to obtain a tympanic membrane temperature is the correct technique for adults and older children. This helps to straighten the ear canal and allow the light to reflect on the tympanic membrane, which shares the same vascular artery as the hypothalamus.
Choice C is wrong because counting the client’s radial pulse who is supine with the forearm straight alongside the body is an appropriate method.
The radial pulse can be easily palpated at the wrist, and the supine position and straight forearm do not affect the pulse rate.
Choice D is wrong because counting the respirations for one full minute for a client with tachypnea is a recommended practice.
Tachypnea means rapid breathing, and counting for one full minute can ensure accuracy and detect any variations in the respiratory pattern.
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