Following a gastric resection, a 70-year-old male client is admitted to the Post-Anesthesia Care Unit (PACU). The client was extubated prior to leaving the OR suite. Upon arrival at the PACU, the nurse should first:

Correct Answer: A

Rationale: Adequate air exchange and tissue oxygenation depends upon competent respiratory function. Checking the airway is the nurse's priority action. Obtaining the vital signs is an important action, but is secondary to airway management. Re-orienting a client to time, place, and person and knowing that their surgery is over is important, but is secondary to airway management and taking vital signs. Airway management takes precedence over the physician's orders, unless the orders specifically relate to airway management.

Correct Answer: B

Rationale: The correct answer is B: urinary incontinence is usually temporary. This response is accurate because after the removal of a Foley catheter following a TURP procedure, it is common for patients to experience temporary urinary incontinence due to the bladder needing time to regain its normal function. This explanation reassures the client that his current experience is a normal part of the recovery process and is likely to improve over time with proper management and support. Option A: he should not be concerned, because it will be quickly resolved. This option is incorrect because it may provide false reassurance and not address the client's concerns adequately. It is essential to acknowledge the client's worries and provide accurate information to empower him during his recovery. Option C: he should notify the nurse when this happens. While it is important for the client to communicate any changes or concerns with the healthcare team, this option does not provide the client with the necessary information about the expected course of urinary incontinence post-Foley catheter removal. Option D: this is related to the bladder spasms and will soon stop. This option is incorrect as it provides a specific cause for the incontinence without acknowledging the broader context of post-TURP recovery, which involves multiple factors contributing to urinary symptoms beyond just bladder spasms. In an educational context, it is crucial for nurses to provide accurate and comprehensive information to patients regarding common postoperative experiences like urinary incontinence. By explaining the temporary nature of this symptom, nurses can help alleviate patient anxiety, promote understanding of the recovery process, and enhance overall patient satisfaction and compliance with care plans.

Correct Answer: B

Rationale: The client's size has nothing to do with an NPO status. Clients are at greatest risk for aspiration and vomiting during surgery when food and/or liquids are in the stomach. Preparation on the morning of surgery is time consuming, but it does not affect a client's NPO status. The gallbladder lies under the surface of the liver and is a part of the biliary tract, not the intestinal tract. Cholecystectomy does not involve the intestinal tract or its contents.

Correct Answer: D

Rationale: The client may have a knowledge deficit, but reducing the risk for knowledge deficit is not a postoperative priority nursing diagnosis. The client will have a Foley catheter for a day or two after the surgery. Urinary retention is usually not a problem once the Foley catheter is removed. A client having a cholecystectomy should not be physically impaired. The client is encouraged to begin ambulating soon after surgery. Because of the location of the incision, the cholecystectomy client is reluctant to breath deeply and is at risk for developing pneumonia. These clients have to be reminded and encouraged to take deep breaths.

Correct Answer: C

Rationale: In conducting a primary survey on a trauma patient, a brief neurologic assessment is considered one of the priority elements. This is because assessing the patient's level of consciousness, orientation, and pupillary response provides crucial information about their neurological status and helps identify any potential brain injury or impairment. A complete set of vital signs, while important, comes after the primary survey and should not delay immediate interventions. Palpation and auscultation of the abdomen are part of the secondary survey, which follows the primary survey in trauma care. Initiation of pulse oximetry is also important but falls under the secondary survey as it assesses oxygenation status. Educationally, understanding the prioritization of assessments in trauma care is essential for nurses and healthcare providers to effectively and efficiently manage patients in critical situations. Emphasizing the significance of a brief neurologic assessment in the primary survey reinforces the importance of quickly identifying life-threatening conditions and initiating appropriate interventions to optimize patient outcomes.