Difficulty: Medium
Average Score: 65%
Full-length
Passage / Scenario
The nurse is admitting a client to the unit from the postoperative recovery area after abdominal exploratory surgery.After determining the client's vital signs, which of the following activities should the nurse perform next?
Correct answer
C
Rationale
Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) implementation, complete assessment first (2) assessment, determine what is happening to the patient now (3) correct-assessment, dressing should be checked on admission to the room and frequently for the next several hours (4) inappropriate assessment, it is too soon for infection to occur secondary to surgery