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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Base appraisals on peer review from other AP:
While peer input can provide valuable insights, it's important to gather feedback from various sources, including those who directly interact with the AP, such as clients and nurses.
B. Examine the agency's job description for AP:
The job description provides information about the expectations and responsibilities of the AP. However, performance appraisal should involve more than just a comparison to the job description.
C. Gather information from clients regarding the AP:
This is the correct answer. Clients can provide valuable feedback on the care and services they receive from the AP. Their perspective can contribute to a more comprehensive assessment of the AP's performance.
D. Review the AP's previous performance appraisal:
While reviewing previous appraisals can offer historical context, it's essential to gather current information to assess the AP's current performance and growth.
Correct Answer is C
Explanation
A. Report the fire details to the facility emergency extension:
While reporting the fire details is important, activating the fire alarm takes precedence. The alarm initiates a quicker and broader response to the emergency.
B. Close the door to the client's room:
Closing the door may be a subsequent action to contain smoke and fire, but it is not the immediate priority. Activating the fire alarm ensures a faster response and is crucial for alerting others.
C. Activate the fire alarm.
Activating the fire alarm is the most immediate action to take in the event of a fire. The fire alarm alerts others in the facility, including staff and emergency services, about the potential danger. This rapid notification initiates the emergency response, ensuring a quick and coordinated effort to address the fire situation and safeguard everyone in the vicinity.
D. Turn off electrical equipment:
Turning off electrical equipment is a valid action to prevent further hazards, but it is not the immediate priority. Activating the fire alarm comes first to ensure the safety of everyone in the facility.
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