A nurse is assessing a client 3 days following a hysterectomy. Which of the following findings should the nurse identify as an indication the client is developing a complication?

Increased hemoglobin

Increased urinary output

Unilateral leg swelling

Mild pain at the surgical site

Answer and Explanation

The Correct Answer is C

Rationale:

A. Increased hemoglobin: A rise in hemoglobin is not expected after surgery but also does not suggest a postoperative complication. It may reflect hemoconcentration from mild dehydration or fluid shifts. This finding does not indicate infection, thrombosis, or impaired healing, so it is not a priority concern at this stage.

B. Increased urinary output: Higher urinary output may occur if the client is well-hydrated or receiving IV fluids. This finding does not suggest renal impairment or postoperative complications. As long as urine is clear and the client is stable, increased output is not concerning and requires only routine monitoring.

C. Unilateral leg swelling: One-sided leg swelling is a hallmark sign of deep vein thrombosis, a serious complication after pelvic surgery due to venous stasis and immobilization. A DVT can progress to pulmonary embolism, posing immediate danger. The finding requires prompt evaluation and intervention to prevent life-threatening complications.

D. Mild pain at the surgical site: Mild incisional pain is expected on postoperative day three as tissues heal and inflammation decreases. This finding is typical and manageable with analgesics. As long as pain is not severe or accompanied by fever, redness, or purulent drainage, it does not indicate a complication.

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Correct Answer is C

Explanation

Rationale:

A. Maintain sensory stimulation for the client: While in restraints, minimizing overstimulation is important to reduce agitation and prevent further aggressive behavior. Excessive sensory input can increase stress and escalate the situation rather than support safety.

B. Identify stressors that caused the client's aggression: Understanding triggers is important for long-term behavior management, but it is not the priority while the client is physically restrained. Immediate safety and monitoring take precedence over retrospective analysis.

C. Observe the client's range of movement: Continuous monitoring of the client’s range of motion is essential while restraints are in place to prevent injury, nerve damage, or impaired circulation. Regular checks ensure the restraints are applied safely and that the client maintains mobility as much as possible within safety limits.

D. Hold a critical incident debriefing about the client: Debriefing is important for staff learning and emotional processing after the event, but it occurs after the client is safe and restraints are removed. It is not an action to be performed while the client is restrained.

A. Encourage the client to drink 3000 mL of fluid daily. B. Use soap and water to provide perineal care. C. Place the drainage bag on the bed when transporting the client. D. Change the indwelling urinary catheter tubing every 3 days. E. Empty the drainage bag when it is half-full F. Review the need for the indwelling urinary catheter daily.

Correct Answer is ["B","E","F"]

Explanation

Rationale:

A. Encourage the client to drink 3000 mL of fluid daily: The client has heart failure with a prescribed fluid restriction of 1000 mL/day. Encouraging excess fluid intake could worsen fluid overload and pulmonary edema, so this is not appropriate.

B. Use soap and water to provide perineal care: Proper perineal hygiene with soap and water reduces the risk of introducing bacteria into the urinary tract, helping prevent catheter-associated urinary tract infections (CAUTIs).

C. Place the drainage bag on the bed when transporting the client: The drainage bag should always be kept below the level of the bladder to prevent backflow and contamination. Placing it on the bed increases the risk of infection and is contraindicated.

D. Change the indwelling urinary catheter tubing every 3 days: Routine changing of the catheter tubing is not recommended as it can increase the risk of infection. Tubing should only be changed if it is compromised, soiled, or obstructed.

E. Empty the drainage bag when it is half-full: Regularly emptying the drainage bag before it becomes overly full prevents backflow and reduces bacterial proliferation, helping to decrease UTI risk.

F. Review the need for the indwelling urinary catheter daily: Assessing the ongoing need for the catheter allows for timely removal, which is the single most effective intervention to prevent catheter-associated urinary tract infections.

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A nurse is assessing a client 3 days following a hysterectomy. Which of the following findings should the nurse identify as an indication the client is developing a complication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who became physically aggressive and had to be placed in mechanical restraints. Which of the following actions should the nurse take while the client is in restraints?

Correct Answer is C

Explanation

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Correct Answer is ["B","E","F"]

Explanation

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