NCLEX · General

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

Correct answer

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

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

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