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 C
No explanation
Correct Answer is A
Explanation
A. Monitor fluid intake and output. Monitoring fluid intake and output is essential in patients with multiple myeloma to assess for signs of dehydration or fluid overload, which can occur due to renal complications.
B. Limit weight bearing and ambulation. Limiting weight bearing and ambulation is not a
standard intervention for multiple myeloma unless there are specific complications such as bone fractures.
C. Assess lymph nodes for enlargement. Multiple myeloma primarily affects the bone marrow and plasma cells, not the lymph nodes.
D. Administer calcium supplements. While calcium supplementation may be necessary in some cases of multiple myeloma, it is not a priority action upon admission without further assessment.
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