A nurse is preparing to provide care to a client who is postoperative following an abdominal hysterectomy 24 hr ago. Which of the following scheduled tasks should the nurse perform first?

Discontinue the client's PCA.

Measure the client's vital signs.

Remove the client's indwelling urinary catheter.

Change the client's abdominal dressing

Answer and Explanation

The Correct Answer is B

A. Discontinue the client's PCA:

The discontinuation of the patient-controlled analgesia (PCA) may be necessary, but assessing the client's vital signs is a priority to ensure the client's overall stability and response to the surgery.

B. Measure the client's vital signs:

This is the correct answer. Assessing vital signs is a priority postoperatively to monitor the client's physiological status, detect any signs of complications, and guide further interventions.

C. Remove the client's indwelling urinary catheter:

Removing the urinary catheter may be part of the postoperative care plan, but it is not the immediate priority. Vital sign assessment is crucial for overall patient monitoring.

D. Change the client's abdominal dressing:

Changing the abdominal dressing is an important aspect of postoperative care, but assessing vital signs takes precedence to identify any signs of distress or instability.

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Correct Answer is A

Explanation

A. The client's blood pressure was recorded at 0730 and 1130.

In a change-of-shift report, it is important to communicate vital signs, especially changes in the client's condition. Recording the blood pressure at different times during the shift helps the oncoming nurse understand the client's cardiovascular status and identify trends or potential issues.

B. The client's pain medication was administered twice during this shift:

While medication administration is important information, specifying the number of times pain medication was administered may be less relevant in a brief change-of-shift report. It's more critical to communicate the client's pain level, response to medication, or any concerns related to pain management.

C. The client's enteral feeding bag needs to be changed at 2200:

While enteral feeding is an essential aspect of care, the timing of the feeding bag change may not be as crucial in a change-of-shift report. Instead, it would be more pertinent to communicate any issues related to the client's tolerance of feeding, any changes in feeding rate, or signs of intolerance.

D. The client received a bath and backrub:

Personal care activities, such as a bath and backrub, are essential components of nursing care, but they may be less critical in a change-of-shift report unless there are specific concerns related to the client's skin condition or overall well-being. More emphasis should be placed on clinical assessments and changes in the client's condition.

A. Discard any remaining medication after 10 days. B. Use 0.9% sodium chloride solution as a diluent. C. Roll the vial gently in hands to mix the medication. D. Store the medication at room temperature following reconstitution

Correct Answer is A

Explanation

A. Discard any remaining medication after 10 days:

This is the correct action according to the label. The label specifies that the reconstituted suspension should be discarded after 10 days, emphasizing the importance of not using the medication beyond that period for safety reasons.

B. Use 0.9% sodium chloride solution as a diluent:

The label does not mention the use of 0.9% sodium chloride solution. It specifically provides directions for adding water for reconstitution. Therefore, using sodium chloride solution is not consistent with the instructions.

C. Roll the vial gently in hands to mix the medication:

The label instructs to "Shake vigorously" to wet the powder, not to roll it gently. Shaking is the recommended method for mixing the medication according to the label.

D.Store the medication at room temperature following reconstitution:

The label clearly states that the reconstituted suspension "Must be refrigerated." Storing it at room temperature contradicts the provided instructions

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A nurse is preparing to provide care to a client who is postoperative following an abdominal hysterectomy 24 hr ago. Which of the following scheduled tasks should the nurse perform first?

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