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 ["38"]
Explanation
To calculate the IV flow rate in drops per minute (gtt/min), you can use the following formula:
Flow Rate (gtt/min)=(Volume (mL)/Time (min)) × Drop Factor (gtt/mL)
In this case:
Flow Rate = (150 mL/hr / 60 min/hr) × 15 gtt/mL
Flow Rate=37.5gtt/min
Therefore, the nurse should set the IV flow rate to deliver approximately 38 gtt/min for the dextrose 5% in water IV infusion at 150 mL/hr, rounded to the nearest whole number.
Correct Answer is D
Explanation
A. Complete medication reconciliation when a client moves to a new room on the same unit:
While it's important to update the client's information when they change rooms, this may not necessitate a full medication reconciliation. Medication reconciliation is typically more comprehensive and involves a thorough review of the client's entire medication regimen.
B. Medication reconciliation should be completed whenever the nurse administers a medication:
While it's important to verify medications before administration, a full medication reconciliation involves a broader review of the client's entire medication history and should not necessarily be done each time a single medication is administered.
C. Medication reconciliation can be delegated to an assistive personnel:
Medication reconciliation is a complex process that involves a thorough review of the client's medication history, and it is generally considered a nursing responsibility. Delegating this task to assistive personnel may compromise accuracy and completeness.
D. Include herbal supplements in the medication reconciliation:
This is the correct answer. Herbal supplements can interact with prescribed medications and may impact the client's overall health. Including them in the medication reconciliation process ensures a comprehensive assessment of the client's medication regimen.
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