A nurse is reinforcing discharge teaching with a client who had an abdominal hysterectomy 2 days ago. Which of the following instructions should the nurse include in the teaching?
"Take a shower rather than a tub bath."
"Avoid climbing stairs for 8 weeks."
"Douche with warm water to remove vaginal discharge."
"Expect bright red vaginal bleeding for 1 week following surgery."
The Correct Answer is A
The correct answer is choice A, "Take a shower rather than a tub bath." This is a safety precaution to prevent infection . Choice B is incorrect because clients are encouraged to walk around after surgery to prevent blood clots. Choice C is incorrect because douching after surgery can increase the risk of infection. Choice D is incorrect because bright red vaginal bleeding after surgery warrants a followup with a healthcare provider. Choice B is not correct because clients are encouraged to walk around after surgery to prevent blood clots. Choice C is not correct because douching after surgery can increase the risk of infection. Choice D is not correct because bright red vaginal bleeding after surgery warrants a followup.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is: Choice A: Maintain direct pressure over the site.
Here's the rationale for each choice:
- Choice A: Maintain direct pressure over the site (CORRECT) This is the most important initial step in controlling bleeding for any patient, especially one with hemophilia who has a deficiency in clotting factors. Maintaining pressure directly on the wound helps to form a clot and stop the bleeding.
- Choice B: Check whether the bleeding has stopped While checking for bleeding cessation is important, it shouldn't be the immediate next step after applying a dressing. Maintaining pressure ensures the dressing remains effective. Once pressure is released, you can assess for continued bleeding.
- Choice C: Obtain a radial pulse Assessing the radial pulse is not directly related to managing the bleeding from the laceration. While it's a vital sign, it's not a priority in this situation.
- Choice D: Reinforce the dressing over the site While reinforcing the dressing might be necessary later if it becomes saturated with blood, maintaining direct pressure is the crucial first step.
Correct Answer is A
Explanation
A change in pupil size can indicate an increase in intracranial pressure, which can lead to a life-threatening situation. The nurse should immediately report this finding to the provider.
Choice B is incorrect because difficulty speaking is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.
Choice C is incorrect because inability to follow direction is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.
Choice D is incorrect because right-sided weakness is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.
Choice B: Difficulty speaking is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.
Choice C: Inability to follow direction is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.
Choice D: Right-sided weakness is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.
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