Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
32. A client with a 6-month history of burning pain and weakness to the thumb and first and middle fingers has a carpal tunnel release done with regional anesthesia. In the PACU, the priority nursing assessment should be:
. Orientation to person, place, time, situation.
. Brachial pulse.
. Color, temperature, movement of the fingers.
. Pupil reaction to light.
Test-Taking Tip
Visualize the operative site and choose an option that includes the operative area ( fingers).
Content Area: Adult Health, Circulatory; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Alterations in Body Systems
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
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Answer 1 is incorrect because this procedure is generally done under regional anesthesia. Priority assessment in the postanesthesia care unit (PACU) would involve evaluating whether anesthesia is wearing off and whether there are complications from surgery, such as damage to nerves or blood vessels. Answer 2 is incorrect because the brachial pulse is above the level of the surgery and would not indicate whether damage had occurred to nerves or blood vessels during the procedure. Answer 3 is correct because checking circulation and sensation in the fingers helps to establish that no damage to blood vessels or nerves occurred during surgery, and that postoperative swelling is not damaging those structures. This procedure is usually done under regional anesthesia; return of sensation and movement indicates anesthesia is wearing off appropriately. Answer 4 is incorrect because this procedure is usually done under regional anesthesia with sedation, neither of which would create a risk for alteration in pupil response.