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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Radiation exposure: Radiation exposure can cause aplastic anemia, but if the cause is unknown, it is less likely to be due to a specific and identifiable event like radiation exposure.
B. An autoimmune disorder: When the cause of aplastic anemia cannot be diagnosed, it is often attributed to an autoimmune disorder where the body attacks its own bone marrow cells.
C. Chemotherapy drugs: Chemotherapy drugs can cause aplastic anemia, but this cause would typically be known based on the patient's medical history.
D. Toxins: Toxins can cause aplastic anemia, but like chemotherapy drugs and radiation, this cause would generally be identifiable.
Correct Answer is C
Explanation
A. Menopause is the cessation of menstruation and marks the end of the reproductive years.
B. Menarche is the onset of menstruation and does not describe a phase of the menstrual cycle.
C. The follicular phase begins at the end of menses and ends at ovulation. During this phase, follicles in the ovaries mature, and one dominant follicle is selected for ovulation.
D. The luteal phase follows ovulation and ends with the start of menses. During this phase, the ruptured follicle transforms into the corpus luteum, which secretes progesterone to prepare the uterus for potential implantation of a fertilized egg.
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