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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. In team nursing, an RN assumes the role of a team leader or coordinator. The RN oversees and coordinates the care provided by other team members, which may include licensed practical nurses (LPNs), nursing assistants, and other healthcare professionals. The team collaborates to meet the needs of a group of clients.
B. Caring for the same clients throughout their hospitalization is more characteristic of primary nursing, where an RN takes primary responsibility for the care of a specific group of clients.
C. Linking community resources with clients to ensure quality care is more aligned with case management or community health nursing, where the focus is on coordinating services across healthcare settings and connecting clients with appropriate resources.
D. Providing every aspect of care for a group of clients during a shift is not consistent with team nursing. In team nursing, the workload is distributed among team members, and an RN typically coordinates and oversees the care provided by the team.
Correct Answer is C
Explanation
A. "A client can obtain a copy of their psychotherapy notes":
This statement is incorrect. Psychotherapy notes are generally not accessible to clients without specific authorization.
B. "I can remain logged-on to my computer if I step away for less than 5 minutes":
This statement is incorrect. It is essential to log off from the computer when stepping away to protect the confidentiality of client information.
C. "I will ensure that my screen isn't visible to others when I'm documenting":
This is the correct answer. Ensuring that the computer screen is not visible to others is an important practice to maintain confidentiality. It prevents unauthorized individuals from accessing sensitive client information.
D. "I will create a simple password that is easy to remember":
This statement is not recommended. Passwords should be strong and secure to protect against unauthorized access. Using a simple and easily guessable password compromises the confidentiality of electronic health records.
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