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 C

Explanation

A. While reporting the fire details to the facility emergency extension is important, the immediate action to ensure the safety of everyone in the facility is to activate the fire alarm. Activating the fire alarm alerts the entire facility to the presence of a fire and initiates the appropriate emergency response.

B. Closing the door to the client's room is a secondary action and can be done after activating the fire alarm. However, the priority is to activate the fire alarm to quickly notify others about the potential danger.

C. Activating the fire alarm is the immediate action to take in the event of a fire. This step ensures that the fire response team is alerted, and appropriate emergency measures are initiated promptly.

D. Turning off electrical equipment can be a safety measure, but it is not the first priority when there is an active fire. Activating the fire alarm and ensuring the evacuation of individuals from the area take precedence.

A. The surgeon can obtain informed consent from the client's adult cousin. B. The surgeon should delay surgery until he can obtain informed consent from a parent. C. The surgeon can proceed with the surgery by invoking implied consent. D. The client's pediatrician can obtain implied consent.

Correct Answer is C

Explanation

A. "The surgeon can obtain informed consent from the client's adult cousin."Informed consent must be obtained from a parent or legal guardian for a minor. An adult cousin does not have the legal authority to provide consent unless they are the legal guardian of the minor, which is not indicated in this scenario.

B. "The surgeon should delay surgery until he can obtain informed consent from a parent."Delaying surgery in an emergency situation could endanger the client's life or health. In such cases, waiting for parental consent is not advisable, and other legal mechanisms, such as implied consent, should be used to proceed with necessary treatment.

C. "The surgeon can proceed with the surgery by invoking implied consent."In emergency situations where the client is a minor and the parents or legal guardians are not available to provide consent, the principle of implied consent allows healthcare providers to perform life-saving procedures without explicit consent. The law recognizes that in emergencies, delaying treatment to obtain consent could result in harm, so the surgeon can proceed with the surgery.

D. "The client's pediatrician can obtain implied consent."The concept of implied consent is not something that can be "obtained" by another healthcare provider. It is a legal principle that allows healthcare providers to act in the best interest of the client during an emergency when consent cannot be obtained. The pediatrician does not have a role in obtaining or invoking implied consent in this context; it is the responsibility of the surgeon performing the emergency procedure.

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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

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