The nurse is preparing to complete a physical assessment before surgery. Which assessments should the nurse obtain?
1. Mini mental status
2. Assessment of hearing
3. Assessment of the respiratory system
4. Gastrointestinal assessment
5. Maintain NPO status
Correct Answer: 1, 2, 3, 4
Rationale 1: A brief or "mini" mental status examination provides valuable baseline data for evaluating the client's mental status and alertness after surgery. It is also important to evaluate the client's ability to understand what is happening.
Rationale 2: Assessment of hearing helps guide the effectiveness of perioperative teaching.
Rationale 3: Respiratory assessment not only provides baseline data for evaluating the client's postoperative status but may alert care providers to a problem that may affect the client's response to surgery and anesthesia.
Rationale 4: The gastrointestinal status provides baseline data.
Rationale 5: Maintaining NPO status is a nursing intervention. It is not included in the physical assessment.
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