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NCLEX · Safety and Infection Control

A nurse receives a client returning from surgery. What is the priority assessment?

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Correct answer

Airway, breathing, and circulation (ABCs) — including respiratory status, vital signs, and level of consciousness

  1. A Airway, breathing, and circulation (ABCs) — including respiratory status, vital signs, and level of consciousness
  2. B The client's insurance information
  3. C The client's visiting schedule
  4. D The client's dietary preferences

Why this is the answer

For a POST-OPERATIVE client, the priority assessment follows the ABCs: AIRWAY (patent? — risk of obstruction from sedation/anesthesia), BREATHING (respiratory rate, depth, oxygen saturation — anesthesia depresses respiration), CIRCULATION (vital signs, bleeding, perfusion), and level of consciousness. NCLEX safe care/post-op safety. Post-op priorities also include: monitoring for hemorrhage (check the surgical site/dressing), assessing pain, monitoring for complications (airway compromise, hypoventilation, hypotension, hemorrhage), and ensuring the client is recovering from anesthesia safely. The immediate post-op period carries risks of airway/respiratory compromise, so ABCs come first. Knowing to prioritize ABCs in the post-op assessment is a commonly tested NCLEX concept.
Source: NCLEX Safe Care — Post-Operative Priority Assessment

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About this topic: Safety and Infection Control

Safety and infection control questions cover Standard and transmission-based precautions, isolation set-up, sterile technique, error prevention, restraints, and emergency and disaster response. This is one of 24 RN: Safe and Effective Care Environment questions on safety and infection control, each with a full explanation on a single study page.

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