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A client has just returned from a total abdominal hysterectomy and needs postoperative nursing care. What action can the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Assess heart, toileting, and bowel sounds.
- B. Check the hemoglobin and hematocrit levels.
- C. Evaluate the dressing for drainage.
- D. Monitor the client for a urinary output.
Correct Answer: D
Rationale: The UAP is able to empty the urinary output from the catheter. The nurse would assess the heart, lung, and bowel sounds; check the hemoglobin and hematocrit levels; and evaluate the drainage on the dressing.
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A client is scheduled to start external beam radiation therapy (EBRT) for her endometrial cancer. Which teaching by the nurse is accurate? (Select all that apply.)
- A. You will need to be hospitalized during this therapy.
- B. Your skin needs to be inspected daily for any breakdown.
- C. It is not wise to stay out in the sun for long periods of time.
- D. The technician applies new site markings before each treatment.
Correct Answer: B,C,D
Rationale: EBRT is usually performed in ambulatory care and does not require hospitalization. The client needs to know to evaluate the skin, especially in the perineal area, for any breakdown, and avoid sunbathing. The client needs to avoid washing off the markings that indicate the treatment site.
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 a temperature of 99.6°F and a pulse of the last 2 hours
- B. Client with a temperature of 99.0°F and blood pressure of 115/73 mm Hg
- C. Client who has pain of 6 on a scale of 0 to 10
- D. Client with a urinary catheter output of 150 mL in the last 3 hours
Correct Answer: A
Rationale: None of 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.
The nurse is caring for a postoperative client following an anterior colporrhaphy. What action can be delegated to the unlicensed assistive personnel (UAP)?
- A. Reviewing the hematocrit and hemoglobin results
- B. Reading the hematocrit and hemoglobin results to an old grandson
- C. Assessing the level of pain and any drainage
- D. Drawing a shallow hot bath for comfort measures
Correct Answer: D
Rationale: The UAP is able to provide comfort through a bath. The registered nurse should review any laboratory results, complete any teaching, and assess pain and discharge.
A client has undergone a vaginal hysterectomy with a bilateral salpingo-oophorectomy. She is concerned about a loss of libido. What intervention by the nurse would be best?
- A. Suggest increasing vitamins and supplements daily.
- B. Discuss the value of a balanced diet and exercise.
- C. Reinforce that weight gain may be inevitable.
- D. Teach that estrogen cream inserted vaginally may help.
Correct Answer: D
Rationale: Use of vaginal estrogen cream and gentle dilation can help with vaginal changes and loss of libido. Weight gain and masculinization are misperceptions after a vaginal hysterectomy. Vitamins, supplements, a balanced diet, and exercise are helpful for healthy living, but are not necessarily going to increase libido.
A client has scheduled brachytherapy sessions and states that she feels as though she is not safe around her family. What is the best response by the nurse?
- A. You are only radioactive when the radioactive implant is in place.
- B. To be totally safe, it is a good idea to sleep in a separate room.
- C. It is best to stay a safe distance from friends or family between treatments.
- D. You should use a separate bathroom from the rest of the family.
Correct Answer: A
Rationale: In brachytherapy, the surgeon inserts an applicator into the uterus. After placement is verified, the radioactive isotope is placed in the applicator for several minutes for a single treatment. There are no restrictions for the woman to stay away from her family or the public between treatments.