A nurse is caring for a client who had an abdominal hysterectomy. The nurse observes that the client has a low-grade fever, foul-smelling vaginal discharge and lower abdominal tenderness. Which of the following actions should the nurse take first?

Notify the provider of the findings.

Obtain a wound culture from the surgical site.

Administer an antibiotic as ordered.

Increase the frequency of perineal care.

Answer and Explanation

The Correct Answer is A

Choice A reason:

The client has signs of a possible infection, such as low-grade fever, foul-smelling vaginal discharge and lower abdominal tenderness. These are complications of hysterectomy that require immediate attention from the provider. The provider may order further tests, such as a wound culture or blood tests, and prescribe antibiotics or other treatments. Therefore, notifying the provider is the first action the nurse should take.

Choice B reason:

Obtaining a wound culture from the surgical site may be necessary to identify the type of infection and the appropriate antibiotic therapy. However, this is not the first action the nurse should take. The nurse should first notify the provider of the findings and follow their orders.

Choice C reason:

Administering an antibiotic as ordered may help treat the infection and reduce the risk of further complications. However, this is not the first action the nurse should take. The nurse should first notify the provider of the findings and obtain a wound culture if ordered to determine the best antibiotic for the client.

Choice D reason:

Increasing the frequency of perineal care may help prevent or reduce infection by keeping the area clean and dry. However, this is not the first action the nurse should take. The nurse should first notify the provider of the findings and administer an antibiotic as ordered to treat the infection.

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Correct Answer is B

Explanation

A. Administering oxygen may help improve oxygen saturation, but the primary concern is hypotension and tachycardia, which suggest possible hypovolemia.
B. The patient’s vital signs, BP 90/60 mmHg, pulse 120 beats/min, urine output 20 mL/h, indicate early hypovolemic shock. The priority intervention is to increase intravenous fluids to restore circulating volume and perfusion.
C. Notifying the physician is important but should follow initiating immediate interventions to stabilize the patient.
D. Administering pain medication does not address the patient’s hemodynamic instability and is not a priority at this time.

A. "I will use a pillow between my legs when I sleep.” B. "I will avoid crossing my legs or bending forward.” C. "I will report any signs of infection or bleeding to my doctor.” D. "I will resume my normal activities as soon as I feel better.” E. "I will take my anticoagulant medication as prescribed."

Correct Answer is ["D","E"]

Explanation

Choice A reason:

This is a correct statement by the client. Using a pillow between the legs when sleeping helps to maintain the hip in abduction and prevent dislocation of the prosthesis.

Choice B reason:

This is also a correct statement by the client. Avoiding crossing the legs or bending forward prevents excessive flexion of the hip and reduces the risk of dislocation.

Choice C reason:

This is another correct statement by the client. Reporting any signs of infection or bleeding to the doctor is important to prevent complications such as wound infection, hematoma, or sepsis.

Choice D reason:

This is an incorrect statement by the client that indicates a need for further teaching. Resuming normal activities as soon as the client feels better is not advisable, as it may cause excessive stress on the joint and lead to loosening or fracture of the prosthesis. The client should follow a gradual rehabilitation program and avoid activities that involve high impact, twisting, or lifting.

Choice E reason:

This is also an incorrect statement by the client that indicates a need for further teaching. Taking anticoagulant medication as prescribed is not enough to prevent thromboembolic events after a total hip replacement. The client should also wear compression stockings, use intermittent pneumatic compression devices, and perform ankle and foot exercises as instructed. The client should also monitor for signs of bleeding or bruising and report any abnormal findings to the doctor.

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A nurse is caring for a client who had an abdominal hysterectomy. The nurse observes that the client has a low-grade fever, foul-smelling vaginal discharge and lower abdominal tenderness. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is reviewing the discharge instructions for a client who had a total hip replacement. Which of the following statements by the client indicate a need for further teaching? (Select all that apply.)

Correct Answer is ["D","E"]

Explanation

A nurse is caring for a client who had an abdominal hysterectomy. The nurse observes that the client has a low-grade fever, foul-smelling vaginal discharge and lower abdominal tenderness. Which of the following actions should the nurse take first?

A nurse is monitoring a patient's temperature after surgery. The patient has a fever of 38.5°C (101.3°F) and chills. What is the most likely cause of the fever?

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