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 C

Explanation

A. Providing the client's breakfast is an essential aspect of diabetes care, but obtaining information about the client's blood glucose level is a priority before administering insulin or making decisions about meal planning.

B. Obtaining the client's capillary blood glucose level is a critical first step. Knowing the current blood glucose level guides the nurse in determining the appropriate insulin dosage, assessing the need for any adjustments in the treatment plan, and planning the client's breakfast based on their current glucose level.

C. Checking the calibration of the glucometer is the first action to ensure the accuracy of the blood glucose measurement. Regular calibration checks help maintain the precision of the glucometer and ensure reliable results.

D. Administering prescribed insulin is an important step in managing type 1 diabetes, but the dosage should be determined based on the client's current blood glucose level. Administering insulin without knowing the current glucose level could lead to inappropriate dosage and potential complications.

A. Flush the tube with 5 mL of water. B. Test the pH of fluid aspirated from the tube. C. Inject air through the tubing and auscultate for gurgling sounds: D. Change the bag and tubing system every 12 hr

Correct Answer is B

Explanation

A. Flush the tube with 5 mL of water:

Explanation: Flushing the tube with water is a routine practice before and after administering medications or feedings to maintain tube patency. However, it is not the primary action to confirm tube placement.

B. Test the pH of fluid aspirated from the tube (Correct Answer):

Explanation: Testing the pH of aspirated fluid helps confirm that the tube is in the stomach. A pH between 1 and 5 is generally indicative of gastric placement.

C. Inject air through the tubing and auscultate for gurgling sounds:

Explanation: This method is an older practice and is not recommended as a reliable method for verifying tube placement. Testing the pH is a more accurate and preferred method.

D. Change the bag and tubing system every 12 hr:

Explanation: Changing the bag and tubing system every 12 hours is a routine practice to maintain the integrity of the enteral feeding system. However, it is not specifically related to the initial steps in verifying tube placement.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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