When a patient arrives in the PACU with a surgical dressing, an intravenous infusion, and a urinary catheter, the priority action of the nurse is assessment of:

IV line patency

urine output

airway patency

wound drainage

Answer and Explanation

The Correct Answer is C

A. IV line patency: IV access is important for fluid and medication administration, but it is not the highest priority immediately postoperatively.

B. Urine output: Monitoring urine output is important for assessing kidney function and fluid balance, but airway management takes precedence.

C. Airway patency: The priority in the immediate postoperative period is maintaining a patent airway, as patients are at risk for respiratory complications such as obstruction, hypoxia, and aspiration due to anesthesia effects.

D. Wound drainage: Assessing wound drainage is necessary to monitor for excessive bleeding or infection, but it is not the top priority compared to airway patency.

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Correct Answer is A

Explanation

A. "They'll improve your circulation to keep blood from pooling in your legs." Antiembolism stockings apply graduated compression, promoting venous return and preventing deep vein thrombosis (DVT) by reducing blood stasis.

B. "They'll make it easier for you to do leg exercises after your surgery." Leg exercises help prevent DVT, but antiembolism stockings do not directly assist in performing them.

C. "They'll protect your legs and heels from skin breakdown." While stockings provide some skin protection, their primary function is to prevent venous stasis and embolism, not to prevent pressure ulcers.

D. "They'll help keep you warm immediately after your surgery." Stockings are not primarily designed for warmth; their main purpose is to prevent clot formation by improving circulation.

A. Initiate protective isolation. B. Perform hand hygiene prior to dressing changes. C. Clean the incision with soap and water. D. Allow the wound to air periodically.

Correct Answer is B

Explanation

A. Initiate protective isolation. Protective isolation is for immunocompromised patients and does not prevent incisional infections.

B. Perform hand hygiene prior to dressing changes. Hand hygiene is the most effective way to prevent infection by reducing the transmission of microorganisms.

C. Clean the incision with soap and water. Surgical incisions should be cleaned with an antiseptic solution, not soap and water, to prevent bacterial contamination.

D. Allow the wound to air periodically. Keeping the wound covered helps prevent exposure to bacteria and contaminants.

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When a patient arrives in the PACU with a surgical dressing, an intravenous infusion, and a urinary catheter, the priority action of the nurse is assessment of:

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Naxlex Comprehensive Predictor Exams

A nurse is reinforcing preoperative teaching with a client who will undergo abdominal surgery. The nurse explains that the client will wear antiembolism stockings after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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When a patient arrives in the PACU with a surgical dressing, an intravenous infusion, and a urinary catheter, the priority action of the nurse is assessment of: