The following 4 questions pertain to this case study:

Exhibits

The post-surgical unit nurse receives the patient from the PACU. Select four priority assessments the post-surgical unit nurse should complete.

Assess the surgical dressing.

Obtain the vital signs.

Assess the pain level.

Assess the respiratory rate and effort.

Ask the patient if they have a ride home.

Answer and Explanation

Correct Answer : A,B,C,D

Choice A reason:

Assessing the surgical dressing is crucial to monitor for signs of bleeding, infection, or other complications at the surgical site. The nurse should check the dressing for any excessive drainage, unusual color, or odor, which could indicate an infection or other issues. Ensuring the dressing is intact and clean helps in preventing wound contamination and promotes healing. This assessment is vital in the immediate postoperative period to detect any early signs of complications that may require prompt intervention.

Choice B reason:

Obtaining the vital signs is a fundamental assessment that provides critical information about the patient’s overall physiological status. Vital signs include blood pressure, heart rate, respiratory rate, and temperature. These measurements help in identifying any deviations from the normal ranges that could indicate complications such as hypovolemia, infection, or respiratory distress. Regular monitoring of vital signs allows the nurse to detect and respond to any changes in the patient’s condition promptly. Normal ranges for adults are typically: blood pressure 120/80 mmHg, heart rate 60-100 beats per minute, respiratory rate 12-20 breaths per minute, and temperature around 98.6°F (37°C).

Choice C reason:

Assessing the pain level is essential for effective pain management and patient comfort. Postoperative pain can significantly impact a patient’s recovery and ability to participate in necessary activities such as deep breathing and ambulation. The nurse should use a standardized pain assessment tool, such as the Numeric Rating Scale (0-10), to evaluate the patient’s pain intensity and quality. Effective pain management involves administering prescribed analgesics and evaluating their effectiveness, as well as implementing non-pharmacological interventions as needed. Proper pain control helps in reducing stress, promoting healing, and improving the overall recovery experience.

Choice D reason:

Assessing the respiratory rate and effort is critical to ensure that the patient is breathing adequately and not experiencing respiratory distress. Anesthesia and surgery can affect respiratory function, making it essential to monitor for signs of hypoxia, such as increased respiratory rate, use of accessory muscles, or cyanosis. The nurse should observe the patient’s breathing pattern, listen to breath sounds, and measure oxygen saturation levels using a pulse oximeter. Normal oxygen saturation levels are typically between 95-100%. Prompt identification and management of respiratory issues are crucial to prevent complications such as atelectasis and pneumonia.

Choice E reason:

Asking the patient if they have a ride home is not a priority assessment in the immediate postoperative period. While discharge planning is important, the primary focus should be on stabilizing the patient’s physiological status and addressing any immediate postoperative needs. Ensuring the patient has a ride home can be addressed later in the recovery process, once the patient is stable and ready for discharge. The initial assessments should prioritize monitoring for complications and ensuring the patient’s safety and comfort.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A: Demonstrate a caring attitude to the patient and family
While demonstrating a caring attitude is an essential aspect of nursing, it is not the primary goal of pain assessment. A caring attitude helps build trust and rapport with patients and their families, which is crucial for effective communication and overall patient care. However, the main objective of pain assessment is to gather data that will inform pain management strategies.
Choice B: Ensure complete documentation in the EHR
Ensuring complete documentation in the Electronic Health Record (EHR) is important for maintaining accurate patient records and facilitating communication among healthcare providers. However, this is a secondary goal that supports the primary objective of pain assessment. The main focus of pain assessment is to collect data that will guide pain management interventions.
Choice C: Gather subjective and objective data in order to plan and implement appropriate pain management techniques
This is the correct answer. The primary goal of a nursing pain assessment is to gather both subjective data (patient’s self-reported pain levels, descriptions, and experiences) and objective data (observations, vital signs, and physical assessments). This comprehensive data collection allows nurses to develop and implement effective pain management plans tailored to the individual needs of the patient. Accurate pain assessment is crucial for identifying the type, intensity, and cause of pain, which in turn informs the selection of appropriate pain relief measures.
Choice D: Develop a therapeutic relationship with the patient
Developing a therapeutic relationship with the patient is an important aspect of nursing care, as it fosters trust and open communication. However, it is not the primary goal of pain assessment. The main objective of pain assessment is to gather data that will inform pain management strategies. A therapeutic relationship can enhance the effectiveness of pain assessment and management, but it is a means to an end rather than the end itself.

A. Monitor for signs and symptoms of infection. B. Provide all patients with bottled water. C. Provide education on infection prevention. D. Request an antibiotic order for a febrile patient. E. Create a clean, safe environment.

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

Explanation

Choice A: Monitor for signs and symptoms of infection

Monitoring for signs and symptoms of infection is a fundamental strategy in infection prevention. Early detection of infections allows for timely intervention, which can prevent the spread of pathogens and reduce the severity of the infection. Common signs and symptoms include fever, redness, swelling, pain, and discharge. Regular monitoring helps healthcare providers identify infections early and take appropriate actions, such as isolating the patient or starting treatment.

Choice B: Provide all patients with bottled water

Providing all patients with bottled water is not a standard infection prevention strategy. While ensuring access to clean drinking water is important, it is not specifically aimed at preventing infections. In healthcare settings, tap water is usually safe to drink if it meets regulatory standards. Bottled water may be provided in certain situations, such as during an outbreak of waterborne pathogens, but it is not a routine infection prevention measure.

Choice C: Provide education on infection prevention

Providing education on infection prevention is crucial for both healthcare providers and patients. Education helps individuals understand how infections spread and what measures they can take to prevent them. This includes proper hand hygiene, respiratory etiquette, and the importance of vaccinations. Educating patients and staff can significantly reduce the incidence of healthcare-associated infections by promoting adherence to infection control practices.

Choice D: Request an antibiotic order for a febrile patient

Requesting an antibiotic order for a febrile patient is not an infection prevention strategy but rather a treatment approach. Antibiotics are used to treat bacterial infections, not to prevent them. Overuse of antibiotics can lead to antibiotic resistance, making it crucial to use them judiciously and only when necessary. Infection prevention focuses on measures to prevent the occurrence of infections rather than treating them once they occur.

Choice E: Create a clean, safe environment

Creating a clean, safe environment is essential for infection prevention in healthcare settings. This involves regular cleaning and disinfection of surfaces, proper waste disposal, and maintaining hygiene standards. A clean environment reduces the risk of healthcare-associated infections by minimizing the presence of pathogens. Effective cleaning protocols and environmental controls are critical components of infection prevention strategies.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The following 4 questions pertain to this case study: Exhibits The post-surgical unit nurse receives the patient from the PACU. Select four priority assessments the post-surgical unit nurse should complete.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A priority goal of the nursing pain assessment is to:

Correct Answer is C

Explanation

Infection prevention strategies include:

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

Explanation

The OR nurse gives an SBAR to the PACU nurse. This verbal report should include which four statements?

Myelosuppression is one of the most common effects of chemotherapy. How would the nurse assess for this condition?

Chemotherapy drugs cannot selectively distinguish between normal cells and cancer cells.

IV potassium chloride (KCl) 60 mEq is prescribed for a 49-year-old female patient with severe hypokalemia. Which action should the nurse take?

Exhibits Select 4 interventions, assessments, and patient education strategies you would use to decrease the risk of a Healthcare-Associated Infection (HAI) for Mr. Johnson.

Instructions: Use this scenario for the next 4 questions. Exhibits Indicate 5 findings in the assessment and laboratory results which require follow-up by the nurse.

The next 3 questions relate to this case study: Exhibits In the event of a reaction or side effect during Ms. Anderson’s chemotherapy session, select the immediate nursing interventions you would take. Select all that apply.

Which information will the nurse consider when deciding what nursing actions to delegate to a licensed practical/vocational nurse (LPN/VN) who is working on a medical-surgical unit?

The following 4 questions pertain to this case study:

Exhibits

The post-surgical unit nurse receives the patient from the PACU. Select four priority assessments the post-surgical unit nurse should complete.