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. Disinfecting hands using an alcohol-based waterless antiseptic is not effective against Clostridium difficile spores. C. difficile is a bacterium that forms spores, which are resistant to alcohol-based hand sanitizers. Handwashing with soap and water is recommended for effective removal of the spores.

B. Wearing an N95 respirator is not specifically indicated for caring for clients with Clostridium difficile. The primary mode of transmission for C. difficile is fecal-oral, and standard precautions, including gloves and gowns, are usually sufficient. N95 respirators are more commonly used for airborne precautions.

C. Using diluted bleach to clean soiled equipment is the correct instruction. Clostridium difficile spores are resistant to many disinfectants, but bleach (sodium hypochlorite) is effective in killing C. difficile spores. Diluted bleach solutions are recommended for cleaning surfaces and equipment that may be contaminated with C. difficile.

D. Providing a room with negative-pressure airflow is not typically necessary for clients with Clostridium difficile. Standard precautions, including appropriate cleaning and disinfection, are generally sufficient to prevent the spread of C. difficile in healthcare settings.

A. Complete an incident report. B. Receive a hepatitis C immunization. C. Notify the health department. D. Start prophylactic antibiotic therapy

Correct Answer is A

Explanation

A. Complete an incident report.

Reporting a needlestick injury through an incident report is crucial. It documents the details of the incident, which is important for the nurse's safety and for initiating appropriate follow-up actions.

B. Receive a hepatitis C immunization:

There is no specific hepatitis C vaccine available. While there are vaccines for hepatitis A and hepatitis B, there is currently no vaccine to prevent hepatitis C. Seeking post-exposure prophylaxis and follow-up is more relevant in this case.

C. Notify the health department:

Notifying the health department might be necessary in some cases, but the immediate action for the nurse is to report the incident through an incident report within the facility. This allows for prompt internal investigation and necessary measures.

D. Start prophylactic antibiotic therapy:

Prophylactic antibiotic therapy is not the standard protocol for preventing hepatitis C transmission after a needlestick injury. Antiviral medications might be considered in certain cases for post-exposure prophylaxis for hepatitis C, but this decision should be made after consulting with a healthcare provider or infectious disease specialist based on the specific circumstances of the exposure. Reporting the incident remains the immediate priority.

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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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Explanation

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Correct Answer is A

Explanation

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