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 A
Explanation
A. Repositioning the client by log-rolling is a critical intervention after lumbar laminectomy surgery. Log-rolling involves turning the entire body as a unit to prevent twisting or bending at the waist, which can strain the surgical site and potentially cause injury. This method helps protect the spine and maintain alignment during movement.
B. Placing a pillow under the client's back while supine is generally not recommended after a lumbar laminectomy. It may cause hyperextension of the spine, leading to discomfort and potential strain on the surgical site.
C. Removing the back brace when the client is out of bed is not a standard practice without specific orders from the surgeon. Back braces are often prescribed for support and stabilization during movement, especially in the early postoperative period.
D. Maintaining the head of the bed at 90° is not advisable after a lumbar laminectomy. The positioning of the bed should be individualized based on the surgeon's preferences, but typically, keeping the bed flat or in a slightly elevated position is more appropriate to reduce strain on the surgical site.
Correct Answer is ["0.7"]
Explanation
To calculate the volume (mL) that the nurse should administer, we can follow these steps:
Convert the weight from pounds to kilograms.
1 lb=0.453592 kg.
66 lb×0.453592 kg/lb≈29.937 kg
Calculate the total dose using the weight and prescribed dose:
Total Dose (mg)=Dose per kg×Weight (kg)
Total Dose=0.55 mg/kg×29.937 kg≈16.465 mg
Determine the volume using the concentration of the available solution:
Volume (mL) =Total Dose (mg)/Concentration (mg/mL)
Volume=16.465mg/25 mg/mL≈ 0.6586 mL
Therefore, the nurse should administer approximately 0.7 mL of chlorpromazine for the 0.55 mg/kg IM dose, rounded to the nearest tenth.
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