When developing the plan of care for a woman who has had an abdominal hysterectomy, the nurse would identify which action as contraindicated?

encouraging range-of-motion exercises

ambulating the client

applying elasticized stockings

massaging the client's legs

Answer and Explanation

The Correct Answer is C

A. Encouraging range-of-motion exercises: Range-of-motion exercises are generally encouraged post-hysterectomy to prevent complications such as blood clots and promote circulation. This action is appropriate and not contraindicated.

B. Ambulating the client: Ambulation is an essential aspect of postoperative care to prevent complications like atelectasis, pneumonia, and deep vein thrombosis (DVT). This action helps improve circulation and aids in the recovery process. It is appropriate and not contraindicated.

C. Applying elasticized stockings: Elasticized stockings, also known as compression stockings, are commonly used postoperatively to prevent deep vein thrombosis (DVT) by promoting blood flow in the legs. However, in the case of abdominal hysterectomy, if the incision site is below the level of the stockings, they may impede circulation to the surgical site and hinder wound healing. Therefore, this action may be contraindicated depending on the specific circumstances of the surgery and incision site.

D. Massaging the client's legs: Massaging the client's legs is generally not recommended post-hysterectomy, especially in the immediate postoperative period. Manipulating the legs could potentially disrupt healing tissues, increase the risk of bleeding, or cause discomfort to the client. Therefore, this action may be contraindicated.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Recurrent pelvic infections:

Pelvic infections, particularly those affecting the fallopian tubes (such as pelvic inflammatory disease), can lead to scarring and damage to the fallopian tubes. Scar tissue can obstruct the normal passage of the fertilized egg, increasing the risk of ectopic pregnancy.

B. Heavy, irregular menses:

While irregular menstrual cycles can sometimes be associated with conditions like polycystic ovary syndrome (PCOS), heavy and irregular menses are not typically considered direct risk factors for ectopic pregnancy. However, underlying conditions contributing to irregular menstrual cycles, such as hormonal imbalances or conditions affecting the reproductive organs, could potentially increase the risk.

C. Use of oral contraceptives for 5 years:

Oral contraceptives (birth control pills) are known to significantly reduce the risk of ectopic pregnancy. They work by preventing ovulation and altering the uterine lining, making it less likely for a fertilized egg to implant outside the uterus. Therefore, long-term use of oral contraceptives would generally decrease the risk of ectopic pregnancy rather than increase it.

D. Ovarian cyst 2 years ago:

While ovarian cysts are common and usually benign, they typically do not directly contribute to the risk of ectopic pregnancy. However, certain types of ovarian cysts, such as those associated with conditions like polycystic ovary syndrome (PCOS) or endometriosis, may indirectly affect fertility and increase the risk of complications during pregnancy, including ectopic pregnancy.

A. Attach a sign above her bed to have BP, IV lines, and lab work in her right arm. B. Encourage her to turn, cough, and deep breathe at frequent intervals. C. Position her right arm below heart level. D. Ask the client how she feels about having her breast removed.

Correct Answer is C

Explanation

A. Attach a sign above her bed to have BP, IV lines, and lab work in her right arm.

- This option is not appropriate because after a right-sided modified-radical mastectomy, it's generally contraindicated to use the affected arm (right arm in this case) for blood pressure measurements, IV lines, or blood draws. This is because such procedures can impede lymphatic drainage and increase the risk of lymphedema. Therefore, the unaffected arm is typically preferred for these purposes to reduce the risk of complications.

B. Encourage her to turn, cough, and deep breathe at frequent intervals.

- While turning, coughing, and deep breathing are essential postoperative nursing interventions to prevent respiratory complications such as pneumonia, they are not specific to the unique needs of a woman who has undergone a mastectomy. These interventions are more focused on general postoperative care rather than addressing the specific concerns related to mastectomy, such as lymphedema management.

C. Position her right arm below heart level.

- This is the correct choice. Positioning the right arm below heart level helps reduce swelling and promotes lymphatic drainage, particularly after surgery involving the lymph nodes, as in a mastectomy. This positioning aids in preventing complications such as lymphedema and supports optimal circulation and fluid balance in the affected arm.

D. Ask the client how she feels about having her breast removed.

- While emotional support and addressing the client's feelings are important aspects of care for a woman who has undergone a mastectomy, this intervention is more appropriate during psychosocial assessment and counseling sessions, rather than immediately postoperatively. At this stage, the focus should be primarily on physical recovery and addressing immediate postoperative needs, such as pain management and prevention of complications like lymphedema. Emotional support can certainly be provided, but it should not be the primary intervention immediately following surgery.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

When developing the plan of care for a woman who has had an abdominal hysterectomy, the nurse would identify which action as contraindicated?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing a client's history and physical examination findings. Which information would the nurse identify as contributing to the client's risk for an ectopic pregnancy?

Correct Answer is A

Explanation

A woman who has undergone a right-sided modified-radical mastectomy returns from surgery. Which nursing intervention would be most appropriate for the nurse to include in the client's plan of care at this time?

Correct Answer is C

Explanation

A client is suspected of having a ruptured ectopic pregnancy. Which assessment would the nurse identify as the priority?

Upon entering the room of a client who has had a spontaneous abortion, the nurse observes the client crying. Which response by the nurse would be most appropriate?

During a routine health check-up, a young adult woman asks the nurse about ways to prevent endometrial cancer. Which actions would the nurse most likely include? Select all that apply.

When describing an episode of intimate partner violence, the victim reports attempting to calm the partner down to keep things from escalating. The nurse interprets this behavior as reflecting which phase of the cycle of violence?

The nurse is developing a plan of care for a client who is receiving aggressive drug therapy for treatment of HIV. The goal of this therapy is to:

A nurse is conducting an in-service program for a group of nurses working at the women's health facility about the causes of spontaneous abortion. The nurse determines that the teaching was successful when the group identifies which condition as the most common cause of first trimester abortions?