After ensuring a postoperative client has a patent airway, what is the next most important nursing assessment?

Level of consciousness

Condition of drains

Appearance of the surgical dressing

Stability of vital signs

Answer and Explanation

The Correct Answer is D

A. Level of consciousness: While important, it follows the assessment of vital signs to ensure the client's overall stability.
B. Condition of drains: This is relevant but not as immediate as assessing the stability of vital signs.
C. Appearance of the surgical dressing: This is important but secondary to ensuring the client’s vital signs are stable.
D. Stability of vital signs: This is the most critical next assessment after ensuring a patent airway, as vital signs reflect the client's immediate physiological status and stability.

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Correct Answer is D

Explanation

A. The 22-year-old client who does not understand English: This client can still consent legally if provided with a translator or interpreter to ensure understanding.
B. The 17-year-old client who has two fractured wrists: This client is a minor and would typically need a legal guardian to consent, but their ability to consent is not the primary issue here.
C. The 65-year-old client who cannot read or write: Literacy issues do not necessarily preclude the ability to understand and consent, especially if the consent process is explained to them.
D. The 80-year-old client who is not oriented to the day: This client lacks orientation and thus may not be able to fully understand or make an informed decision about the surgery, affecting their ability to consent legally.

A. Monitor intake and output every shift B. Place the solution on an IV pump at the prescribed rate C. Monitor blood glucose every one (1) hour D. Change the IV tubing every seven (7) days E. Weigh the client weekly, first thing in the morning

Correct Answer is ["A","C","D"]

Explanation

A. Monitor intake and output every shift: Important for tracking fluid balance and ensuring appropriate hydration and nutritional support.
B. Change the IV tubing every seven (7) days: IV tubing should generally be changed every 24 to 72 hours or as per hospital protocol, not every seven days.
C. Place the solution on an IV pump at the prescribed rate: Ensures accurate administration of TPN and prevents complications associated with over or under-infusion.
D. Monitor blood glucose every one (1) hour: Frequent monitoring is required as TPN can cause fluctuations in blood glucose levels.
E. Weigh the client weekly, first thing in the morning: While weighing the client is important, it is typically done more frequently than weekly to monitor fluid status and nutritional response.

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After ensuring a postoperative client has a patent airway, what is the next most important nursing assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is asked to witness surgical consent forms were obtained for clients, in the preoperative holding area. What client would not be able to consent legally to surgery?

Correct Answer is D

Explanation

The client is NPO and is receiving total parenteral nutrition (TPN) via a peripherally inserted central catheter. Which precautions should the nurse implement? (Select All That Apply)

Correct Answer is ["A","C","D"]

Explanation

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