A nurse is caring for a client who had an abdominal hysterectomy. The nurse observes that the client has a low-grade fever, foul-smelling vaginal discharge and lower abdominal tenderness. Which of the following actions should the nurse take first?
Notify the provider of the findings.
Obtain a wound culture from the surgical site.
Administer an antibiotic as ordered.
Increase the frequency of perineal care.
The Correct Answer is A
A. Notify the provider of the findings.
Choice A reason:
The client has signs of a possible infection, such as low-grade fever, foul-smelling vaginal discharge and lower abdominal tenderness. These are complications of hysterectomy that require immediate attention from the provider. The provider may order further tests, such as a wound culture or blood tests, and prescribe antibiotics or other treatments. Therefore, notifying the provider is the first action the nurse should take.
Choice B reason:
Obtaining a wound culture from the surgical site may be necessary to identify the type of infection and the appropriate antibiotic therapy. However, this is not the first action the nurse should take. The nurse should first notify the provider of the findings and follow their orders.
Choice C reason:
Administering an antibiotic as ordered may help treat the infection and reduce the risk of further complications. However, this is not the first action the nurse should take. The nurse should first notify the provider of the findings and obtain a wound culture if ordered to determine the best antibiotic for the client.
Choice D reason:
Increasing the frequency of perineal care may help prevent or reduce infection by keeping the area clean and dry. However, this is not the first action the nurse should take. The nurse should first notify the provider of the findings and administer an antibiotic as ordered to treat the infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Administering an antiemetic as ordered can help prevent postoperative nausea and vomiting by blocking the receptors in the brain that trigger the vomiting reflex. This is a common intervention for clients who have undergone laparoscopic cholecystectomy, as they may experience nausea and vomiting due to the effects of anesthesia, pain, or the carbon dioxide gas used to inflate the abdomen during the procedure.
Choice B reason:
Encouraging the client to drink carbonated beverages is not a good intervention to prevent postoperative nausea and vomiting, as carbonated beverages can increase gastric distension and pressure, which can worsen nausea and vomiting. Carbonated beverages can also cause belching, which can introduce air into the stomach and increase the risk of aspiration.
Choice C reason:
Placing the client in a supine position is not a good intervention to prevent postoperative nausea and vomiting, as supine position can decrease gastric emptying and increase the risk of aspiration. Supine position can also impair respiratory function and cause hypoxemia, which can trigger nausea and vomiting. The client should be placed in a semi-Fowler's position or on their side with their head elevated to facilitate gastric emptying and prevent aspiration.
Choice D reason:
Applying pressure to the client's abdomen is not a good intervention to prevent postoperative nausea and vomiting, as pressure can cause pain and discomfort, which can worsen nausea and vomiting. Pressure can also interfere with wound healing and increase the risk of infection or bleeding. The client's abdomen should be assessed for distension, tenderness, or signs of complications, but not pressed.
Correct Answer is ["D"]
Explanation
The correct answer is choiced. “I will resume my normal activities as soon as I feel better.”
Choice A rationale:Using a pillow between the legs when sleeping is recommended to prevent dislocation of the new hip joint. This helps maintain proper alignment and reduces stress on the hip.
Choice B rationale:Avoiding crossing the legs or bending forward is crucial to prevent dislocation and ensure proper healing of the hip joint. These movements can place undue stress on the new hip.
Choice C rationale:Reporting any signs of infection or bleeding to the doctor is essential for early detection and treatment of complications. This is a standard part of post-operative care.
Choice D rationale:Resuming normal activities as soon as one feels better is not recommended. Patients should follow a gradual rehabilitation plan and the specific instructions of their healthcare provider to avoid complications and ensure proper healing.
Choice E rationale:Taking anticoagulant medication as prescribed is important to prevent blood clots, which are a common risk after hip replacement surgery. This helps ensure the patient’s safety during recovery.
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