A nurse is preparing to provide care to a client who is postoperative following an abdominal hysterectomy 24 hr ago. Which of the following scheduled tasks should the nurse perform first?

Discontinue the client's PCA.

Measure the client's vital signs.

Remove the client's indwelling urinary catheter.

Change the client's abdominal dressing

Answer and Explanation

The Correct Answer is B

A. Discontinue the client's PCA:

The discontinuation of the patient-controlled analgesia (PCA) may be necessary, but assessing the client's vital signs is a priority to ensure the client's overall stability and response to the surgery.

B. Measure the client's vital signs:

This is the correct answer. Assessing vital signs is a priority postoperatively to monitor the client's physiological status, detect any signs of complications, and guide further interventions.

C. Remove the client's indwelling urinary catheter:

Removing the urinary catheter may be part of the postoperative care plan, but it is not the immediate priority. Vital sign assessment is crucial for overall patient monitoring.

D. Change the client's abdominal dressing:

Changing the abdominal dressing is an important aspect of postoperative care, but assessing vital signs takes precedence to identify any signs of distress or instability.

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Correct Answer is A

Explanation

A. Instruct the client to limit flexion of the hips no further than 100°.For a client who is postoperative following a total hip arthroplasty, hip flexion should generally be limited to 90° or less to avoid dislocation of the hip prosthesis. The instruction to limit flexion to 100° could potentially put the client at risk for dislocation and should be clarified.

B. Perform range-of-motion exercises every 2 hr.This helps prevent stiffness and promotes circulation, although passive range of motion should be performed carefully to avoid excessive hip flexion.

C. Reposition the client every 2 hr.Regular repositioning helps prevent pressure ulcers and other complications, and is a standard postoperative practice.

D. Place an abduction pillow between the legs.An abduction pillow is used to keep the legs apart and prevent dislocation of the hip joint, which is essential after a hip arthroplasty.

A. I should wait until I am terminally ill to complete my advance directives." B. "I must name a relative to make decisions for me in my health care proxy." C. I can state in my living will which medical treatments I want done if I am terminally ill." D. "I will make changes to my advance directives if I change my mind about anything." E. I will need to complete a new living will each time I am hospitalized."

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

Explanation

A. "I should wait until I am terminally ill to complete my advance directives."

This statement is incorrect. It is advisable to complete advance directives before a critical or terminal illness occurs to ensure that one's preferences are known and respected in the event of incapacity.

B. "I must name a relative to make decisions for me in my health care proxy."

This statement is incorrect. While naming a relative is a common choice, individuals can choose any competent person as their healthcare proxy, and it does not have to be a family member.

C. "I can state in my living will which medical treatments I want done if I am terminally ill."

This statement is correct. A living will allows individuals to specify the medical treatments they wish to receive or avoid in the event they become terminally ill or incapacitated.

D. "I will make changes to my advance directives if I change my mind about anything."

This statement is correct. Advance directives are not permanent and can be changed or updated if the individual's preferences or circumstances change.

E. "I will need to complete a new living will each time I am hospitalized."

This statement is incorrect. Advance directives, including living wills, are generally not tied to a specific hospitalization. They remain in effect unless the individual chooses to update or change them.

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A nurse is preparing to provide care to a client who is postoperative following an abdominal hysterectomy 24 hr ago. Which of the following scheduled tasks should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the prescriptions for a client who is postoperative following a total hip arthroplasty. Which of the following prescriptions should the nurse clarify with the provider?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client about advance directives. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.)

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

Explanation

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