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. Clay: Individuals with pica due to iron-deficiency anemia may crave and consume substances like clay.
B. Soil: Soil consumption is another manifestation of pica commonly seen in individuals with iron-deficiency anemia.
C. Ice: Some individuals with iron-deficiency anemia may crave and chew ice as a form of pica behavior.
D. Any of the responses: Pica is a condition where individuals have cravings for nonfood substances. In iron-deficiency anemia, pica can manifest as cravings for various nonfood items, including clay, soil, ice, and many others.
Correct Answer is B
Explanation
A. Phalitis: This term is not commonly used and does not specifically refer to swelling in the hands and feet.
B. Dactylitis: Dactylitis is a common manifestation of sickle cell disease in infants, characterized by painful swelling of the hands and feet due to vaso-occlusive episodes.
C. Erythromelaglia: Erythromelalgia is a condition characterized by burning pain, redness, and warmth in the extremities, but it is not typically associated with sickle cell disease.
D. Dyshidrotia: This term is not commonly used in medical terminology and does not specifically refer to swelling in the hands and feet.
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