A nurse is caring for a client following a culdoscopy. Which assessment data would the licensed practical nurse report to the registered nurse?
A) Pain level of 7 on the 0-to-10 pain scale
B) Skin, cold; pulse, 110 beat/minute; blood pressure, 104/64 mm Hg
C) Dark drainage noted on surgical pad
D) Fleshy smell noted to perineal region
B
Feedback:
Culdoscopy is performed to visualize the uterus, broad ligaments, and fallopian tubes. An endoscope is inserted through a small incision made in the posterior vaginal wall. Afterward, the nurse must observe for signs of internal bleeding and shock. A client with cold and clammy skin, a rapid pulse, and low blood pressure indicates shock and the need to consult the registered nurse and even the physician. All of the other symptoms are able to be addressed by the licensed practical nurse. The client is to be medicated. Dark drainage and a fleshy smell to the perineal area are normal for old surgical drainage.
You might also like to view...
An elderly patient complains of an earache and has an oral temperature of 100.2° F. Otoscopic assessment of the ear reveals a pearly gray tympanic membrane with no evidence of discharge or inflammation
Which action should the nurse take next? A) Palpate the patient's parotid glands to detect swelling and tenderness. B) Assess the temperomandibular joint for evidence of a malocclusion. C) Test the integrity of cranial nerve XII by asking the patient to protrude his tongue. D) Inspect the patient's gums for bleeding and hyperpigmentation.
The nurse is caring for a client with major depression. Which statement about this condition does the nurse know to be true?
A) Depression primarily affects older adults due to age-related changes in mood. B) Depression is rarely a debilitating condition. C) Depression can be a fatal illness. D) Depression is part of normal emotional regulation.
As part of secondary prevention, the community health nurse engages in crisis intervention to achieve which of the following?
A) Reestablish equilibrium to the lives of those involved B) Prevent the crisis altogether C) Involve as many people as possible in the resolution D) Triage clients during the recovery phase of the crisis
The nurse is caring for a woman who has just had an uncomplicated abortion. What instructions should the nurse provide? (Select all that apply.)
a. "Call if you bleed for more than 3 days." b. "Call if you have more bleeding than you would during a heavy period." c. "The discharge often has a foul odor due to the procedure." d. "Don't be surprised if you pass clots. Call if they are larger than a golf ball." e. "You can expect moderate bleeding and a low-grade fever for about a week." f. "You should abstain from sexual intercourse as directed by your physician."