A nurse is caring for four postoperative patients who each had a total abdominal hysterectomy. Which patient would the nurse assess first upon initial rounding?
Patient who has pain of "4" on a scale of 0 to 10
Patient with a temperature of 99° F (37.2° C) and blood pressure of 115/73 mm Hg
Patient with a urinary catheter output of 150 mL in the last 3 hours
Patient who has had two saturated perineal pads in the last 2 hours
The Correct Answer is D
A. Pain level of "4" on a scale of 0 to 10 indicates mild pain and may not require immediate attention compared to other potential issues.
B. Vital signs within normal range, including temperature and blood pressure, do not indicate an urgent need for assessment.
C. Urinary catheter output of 150 mL in the last 3 hours is within the expected range postoperatively and does not require immediate assessment.
D. Saturated perineal pads suggest excessive bleeding, which could indicate a potential complication such as hemorrhage. Therefore, the nurse should assess this patient first to ensure prompt intervention if necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Elevated blood pressure above 140/90. While hypertension can occur in middle age, it is not specifically associated with perimenopause.
B. Report of dryness with vaginal intercourse. Vaginal dryness is a common symptom of perimenopause due to decreasing estrogen levels.
C. Report of urinary retention. Urinary symptoms in perimenopause more commonly include frequency and urgency, rather than retention.
D. Elevated body temperature above 37.8° C (100° F). While hot flashes are common during perimenopause, they do not typically cause a sustained elevated body temperature.
Correct Answer is B
Explanation
A. Decreased serum albumin is not typically associated with hemolysis; it may occur in conditions such as liver disease or malnutrition.
B. Jaundice, or yellowing of the skin and eyes, is a common manifestation of hemolysis due to the increased production of bilirubin from the breakdown of red blood cells.
C. Increased serum bilirubin levels occur as a result of hemolysis, contributing to the development of jaundice.
D. Increased bilirubin is essentially the same as increased serum bilirubin; both indicate the presence of jaundice due to hemolysis.
E. Presence of dark urine is also characteristic of hemolysis, as it may contain excess bilirubin, giving it a darker color.
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