Following a laparoscopic-assisted vaginal hysterectomy, which client assessment finding would warrant nursing intervention? Select all that apply
A) Dorsal recumbent positioning with knee bend
B) Early ambulation
C) Peri-pad changed every shift
D) Catheter tube secured to leg
E) TED stockings removed and reapplied twice daily
F) High-fiber diet
A, C
Feedback:
Following abdominal surgery, positioning of the legs with sharp bends can interfere with blood flow and should be avoided. Peri-pad should be changed at least once every 4 hours to observe for bleeding and prevent infection. Early ambulation and application of TED hose promote circulation and decrease risk for thrombophlebitis and embolus formation. Securing the catheter prevents pulling on the bladder neck. High-fiber diet prevents constipation and straining.
You might also like to view...
The nurse is assessing the client's neck. Which finding is considered an abnormality?
1. The client's carotid arteries are visibly pulsating. 2. The neck is symmetrical. 3. The tracheal cartilage does not move when the client swallows. 4. The thyroid has no palpable nodules.
The nurse, in planning care, considers that the two most common opportunistic infections and malignant neoplasms in the HIV-positive patient are:
1. Streptococcal pneumonitis and myeloma. 2. Streptococcus pneumoniae and malignant melanoma. 3. Pneumocystis jiroveci pneumonitis and Kaposi's sarcoma. 4. Mycoplasmal pneumonia and Kaposi's sarcoma.
A three-stage progressive pattern of nonspecific physiologic responses known as alarm, resistance, and exhaustion is based on
a. Cannon's scientific physiologic response theory. b. Selye's General Adaptation Syndrome. c. Holmes and Rahe's stimuli stress model. d. Lazarus and Folkman's transactional model of stress.
The nurse assesses a patient during digital removal of a fecal impaction. Which patient assessment finding does the nurse determine to be unexpected?
a. Complaints of abdominal cramping b. Large amount of brown, liquid stool c. Blood pressure 130/86 mm Hg, stable d. Heart monitor showing sinus bradycardia