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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Hot tea:
Hot tea may not be well-tolerated by individuals experiencing chemotherapy-induced nausea, as hot or strong-smelling foods and beverages can be triggers. It is generally recommended to choose foods at room temperature.
Soft-serve ice cream:
Soft-serve ice cream may be too cold and could exacerbate nausea or discomfort. Cold foods might not be well-tolerated during or after chemotherapy.
Raisin toast:
This is the correct answer. Raisin toast is a good choice as it is a bland and easily digestible carbohydrate. It can be a suitable option for individuals experiencing nausea, providing some calories without strong odors or flavors.
String cheese:
While cheese can be a good source of protein, string cheese might not be the best choice if the individual is experiencing nausea, as the smell or taste of certain cheeses can be strong and trigger nausea.
Correct Answer is ["300"]
Explanation
To calculate the infusion rate (mL/hr), you can use the following formula:
Infusion Rate (mL/hr)=Total Volume (mL)/Total Time (hr)
In this case:
- Infusion Rate=1,800 mL/6 hr
- Infusion Rate=300mL/hr
Therefore, the nurse should ensure the IV pump is set to deliver 300 mL/hr for the 0.9% sodium chloride infusion over 6 hours, rounded to the nearest whole number.
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