Author Question: The nurse is admitting a client to the medical-surgical unit following a cholecystectomy. Which ... (Read 90 times)

ARLKQ · **on:** Jul 23, 2018

The nurse is admitting a client to the medical-surgical unit following a cholecystectomy. Which intervention should the nurse perform first?

1. Level of consciousness
2. Dressing
3. Drains
4. Skin color

Question 2

The nurse is preparing a care plan for a client about to undergo surgery. Which nursing diagnosis would take priority during the intraoperative phase of surgery?

1. Ineffective Protection
2. Risk for Aspiration
3. Impaired Skin Integrity
4. Risk for Falls

asdfasdf · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 1
Rationale 1: The nurse should assess the client's level of consciousness first.
Rationale 2: The operative dressing is not assessed first.
Rationale 3: An operative drains are not assessed first.
Rationale 4: The client's skin color is not assessed first.

Answer to Question 2

Correct Answer: 2
Rationale 1: Although appropriate for a client having surgery, the nurse should prioritize care according to the ABCs or airway, breathing, circulation when planning care.
Rationale 2: This is the priority nursing diagnosis for the client having surgery. The Risk for Aspiration would impact the client's airway and breathing.
Rationale 3: Although appropriate for a client having surgery, the nurse should prioritize care according to the ABCs or airway, breathing, circulation when planning care.
Rationale 4: This nursing diagnosis is not appropriate during the intraoperative phase of care.