A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential problem has the highest priority when planning nursing care for this client?

Activity intolerance.

Fluid volume excess.

Ineffective airway clearance.

Altered nutrition; less than body requirements.

Answer and Explanation

The Correct Answer is C

Choice A reason: Activity intolerance is important but not the highest priority immediately after surgery.

Choice B reason: Fluid volume excess can be a concern but is not as critical as ensuring effective airway clearance.

Choice C reason: Ineffective airway clearance is the highest priority as it directly impacts the client’s ability to breathe and maintain adequate oxygenation, which is crucial for postoperative recovery.

Choice D reason: Altered nutrition is also important but is not the immediate priority compared to airway clearance.

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Correct Answer is A

Explanation

Choice A reason: Relevance to the situation is the most important consideration when gathering evidence to ensure that the information directly addresses the specific clinical question and problem at hand.

Choice B reason: Related personal values are important but secondary to the relevance of evidence in making clinical decisions.

Choice C reason: Frequency that the problem occurs is useful information but not as crucial as ensuring the evidence is directly relevant.

Choice D reason: Past experience with similar problems can inform decision-making but should be supported by relevant and current evidence.

A. Cefazolin 1 gram IV every 6 hours. B. Complete blood cell count (CBC) in AM. C. Advance from clear liquids as tolerated. D. Straight catheterization if unable to void.

Correct Answer is A

Explanation

Choice A reason: Administering cefazolin, an antibiotic, is a priority to prevent or treat potential infections in the immediate postoperative period.

Choice B reason: Completing a CBC in the morning is important for ongoing assessment but is not an immediate priority.

Choice C reason: Advancing the diet as tolerated is important but can be done after ensuring infection prevention.

Choice D reason: Straight catheterization is necessary if the client is unable to void but is not the immediate priority compared to preventing infection.

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A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential problem has the highest priority when planning nursing care for this client?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

Correct Answer is A

Explanation

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