A young adult client has a partner and no children. The client has a hysterectomy because of endometrial cancer. The client has an IV and an indwelling urinary catheter. The client is crying asking for their partner. Which action does the nurse take first?
Assesses the IV site for inflammation
Measures the urine output for the day
Calls the partner to come and visit
Asks the client if pain medication is required
The Correct Answer is C
The client is likely feeling scared, vulnerable, and alone. By calling the partner to come and visit, the nurse can provide the client with emotional support and comfort during this difficult time. This can also help to alleviate the client's distress and promote a sense of security and familiarity.
Assessing the IV site for inflammation (a) and measuring the urine output for the day (b) are important aspects of the client's care, but they are not the priority in this situation. Asking the client if pain medication is required (d) is also important, but it can wait until the client's emotional needs have been addressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A rectal temperature should not be taken if the client has bradycardia because stimulation of the vagus nerve during the insertion of the rectal thermometer can result in a further decrease in heart rate. Hypertension, tachypnea, and pyrexia are not contraindications for taking a rectal temperature.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
The nurse's highest priority is planning care knowing that the client is at risk for seizures due to hydrochlorothiazide (HCTZ) and chemotherapy.
The nurse's highest priority is planning care knowing that the client is at risk for seizures due to the recent initiation of hydrochlorothiazide (HCTZ), which can cause electrolyte imbalances such as hyponatremia, and the history of chemotherapy for ovarian cancer, which may increase the risk of seizure activity.
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