41. A client has just returned from the operating room following a hip replacement. The most important nursing assessment over the next 8 hours is:
41. A client has just returned from the operating room following a hip replacement. The most important nursing assessment over the next 8 hours is:
. Bleeding from the surgical site.
. Respiratory status.
. Urinary output.
. Circulation and sensation on the operative side.
Test-Taking Tip
Use the "B" in the ABCs (airway, breathing, circulation) here when setting priorities for this client. The question asks for the most important assessment, not the only assessment . . . most life-threatening.
Content Area: Adult Health, Musculoskeletal; Integrated Process: Nursing Process, Assessment; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications from Surgical Procedures and Health Alterations
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Answer 1 is incorrect because, while it is important to observe for bleeding, the first concern in the immediate postoperative period is the development of respiratory problems. Answer 2 is correct because the client's respiratory status needs to be monitored closely for the prolonged effects of general anesthesia used during major surgery. Answer 3 is incorrect because, while urinary output also needs to be monitored, the lingering effects of general anesthesia on the respiratory system are minimized with coughing and deep breathing in the early postoperative period. Answer 4 is incorrect because, while this also needs to be monitored, respiratory status is more imminently life-threatening.