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 A
Explanation
A. "You will need to empty your bladder just before the exam.": Emptying the bladder before a pelvic examination allows for better visualization and manipulation of the pelvic organs.
B. "You should douche the evening prior to the examination.": Douching is not recommended before a Pap test as it can disrupt the natural flora of the vagina and may interfere with test results.
C. "You will be required to sign an informed consent prior to the exam.": Informed consent may be required for certain procedures but is not typically needed for a Pap test.
D. "You will be given light sedation before the examination starts.": Sedation is not typically used for a Pap test, which is a simple procedure that does not usually cause significant discomfort.
Correct Answer is ["C","D"]
Explanation
A. The patient experiences a decrease in hemoglobin S. Hydroxyurea does not decrease hemoglobin S levels directly; it works by increasing fetal hemoglobin (Hgb F) levels.
B. The patient experiences dehydration due to diuresis. This is not an indication that Hydroxyurea is working; it is a potential side effect that should be monitored.
C. The patient experiences an increase in fetal hemoglobin (Hbg F). Hydroxyurea works by increasing the levels of fetal hemoglobin, which reduces the sickling of red blood cells.
D. The patient needs fewer blood transfusions. Successful treatment with Hydroxyurea should reduce the frequency of vaso-occlusive crises and the need for blood transfusions.
E. The patient experiences diuresis. This is not an indicator of the medication's effectiveness; it is a potential side effect.
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