A nurse is caring for four postoperative clients who each had a total abdominal hysterectomy. Which client should the nurse assess first upon initial rounding?
a. Client who has had two saturated perineal pads in the last 2 hours
b. Client with a temperature of 99 ° F and blood pressure of 115/73 mm Hg
c. Client who has pain of "4" on a scale of 0 to 10
d. Client with a urinary catheter output of 150 mL in the last 3 hours
ANS: A
Normal vaginal bleeding should be less than one saturated perineal pad in 4 hours. Two saturated pads in such a short time could indicate hemorrhage, which is a priority. The other clients also have needs, but the client with excessive bleeding should be assessed first.
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