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. Changing the dressing is an action that comes after assessing and selecting the appropriate dressing. Before changing the dressing, the nurse needs to gather information and make decisions about the most suitable type of dressing based on the characteristics of the wound.

B. Selecting the appropriate dressing is an essential step, but before doing so, the nurse should review available dressing types to make an informed decision about which dressing will best meet the needs of the wound. This involves considering factors such as the wound's characteristics, exudate level, and the overall condition of the client.

C. Reviewing available dressing types is the first step because it allows the nurse to assess the wound, gather information about the client's condition, and make an informed decision about the most appropriate dressing. This step ensures that the chosen dressing aligns with the wound's characteristics and promotes optimal healing.

D. Documenting the dressing change is an important step in the process, but it typically occurs after the dressing change has been completed. Documentation is crucial for tracking the client's progress, ensuring continuity of care, and providing a record for other healthcare team members.

A. Disinfect hands using an alcohol-based waterless antiseptic. B. Wear an N95 respirator when caring for the client. C. Use diluted bleach to clean soiled equipment. D. Provide a room with negative-pressure airflow.

Correct Answer is C

Explanation

A. Disinfect hands using an alcohol-based waterless antiseptic:

While alcohol-based hand sanitizers are effective against many germs, including bacteria, they may not be as effective against C. difficile. Soap and water are preferable for hand hygiene in C. difficile cases because alcohol does not effectively kill the spores.

B. Wear an N95 respirator when caring for the client:

The primary mode of transmission for C. difficile is through the fecal-oral route, and respiratory precautions are not necessary. Standard precautions, including wearing gloves and gowns, are generally sufficient.

C. Use diluted bleach to clean soiled equipment:

This is the correct answer. Bleach is an effective disinfectant against C. difficile spores. It is recommended for cleaning surfaces and equipment that may be contaminated.

D. Provide a room with negative-pressure airflow:

Negative-pressure airflow rooms are typically reserved for airborne infections, and they are not necessary for C. difficile. Standard precautions, along with thorough cleaning and disinfection, are the key measures.

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