A nurse is caring for four postoperative patients who each had a total abdominal hysterectomy. Which patient would the nurse assess first upon initial rounding?
Patient who has pain of "4" on a scale of 0 to 10
Patient with a temperature of 99° F (37.2° C) and blood pressure of 115/73 mm Hg
Patient with a urinary catheter output of 150 mL in the last 3 hours
Patient who has had two saturated perineal pads in the last 2 hours
The Correct Answer is D
A. Pain level of "4" on a scale of 0 to 10 indicates mild pain and may not require immediate attention compared to other potential issues.
B. Vital signs within normal range, including temperature and blood pressure, do not indicate an urgent need for assessment.
C. Urinary catheter output of 150 mL in the last 3 hours is within the expected range postoperatively and does not require immediate assessment.
D. Saturated perineal pads suggest excessive bleeding, which could indicate a potential complication such as hemorrhage. Therefore, the nurse should assess this patient first to ensure prompt intervention if necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Conscious sedation will be administered to you prior to the procedure." Needle aspiration breast biopsies typically use local anesthesia, not conscious sedation.
B. "The results of the biopsy will be immediately available." Biopsy results usually take a few days to be processed and reviewed.
C. "You may place a heating pad on the breast to relieve discomfort following the procedure." Applying a cold pack, rather than a heating pad, is generally recommended to reduce swelling and bruising.
D. "You should wear a well-fitting bra to minimize bruising following the procedure." Wearing a well-fitting bra can provide support and help minimize bruising and discomfort after the
procedure.
Correct Answer is B
Explanation
A. An endometrial biopsy. This test is used to diagnose endometrial cancer, not cervical cancer.
B. Papanicolaou test. The Pap test (Papanicolaou test) is the preferred and standard method for detecting cervical cancer by identifying precancerous or cancerous cells on the cervix.
C. CA 125. CA 125 is a tumor marker that is often used in the detection and management of ovarian cancer, not cervical cancer.
D. Transvaginal ultrasound. This imaging test is typically used to evaluate ovarian and endometrial abnormalities but is not the preferred method for detecting cervical cancer.
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