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 D
Explanation
A. Remind the client that gonorrhea is a virus, therefore it cannot be cured. Gonorrhea is a bacterial infection caused by Neisseria gonorrhoeae and can be treated with antibiotics.
B. Instruct the client about preventing reinfection by using a diaphragm. While diaphragms can be a method of contraception, they are not effective at preventing sexually transmitted infections like gonorrhea.
C. Check for the presence of a primary lesion or chancre. Primary lesions or chancres are associated with syphilis, not gonorrhea.
D. Obtain information about the client's recent sexual partners. It is important to obtain information about recent sexual partners to notify them and prevent the spread of the infection.
Correct Answer is D
Explanation
A. Syphilis can indeed affect many areas of the body, including the brain and heart, but this statement does not specifically address primary syphilis, which is characterized by the appearance of a painless sore (chancre) at the site of infection.
B. Syphilis does not typically resolve on its own. Without treatment, the infection can progress to more severe stages with potentially serious complications.
C. Syphilis is caused by a bacterial infection (Treponema pallidum) and is treated with antibiotics such as penicillin. Antiviral medications are not effective against bacterial infections like syphilis.
D. This statement is accurate and important for the prevention of syphilis transmission. Syphilis can be transmitted through vaginal, anal, or oral sex, but the risk of transmission is lower during oral sex compared to vaginal or anal intercourse.
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