A nurse is caring for a client.
Click on the findings that require immediate follow-up. To deselect a finding, click on the finding again.
Nurses' Notes
1500:
Client is alert and oriented to person, place, and time. Client is 4 hr postoperative following abdominal surgery. Surgical site has a small amount of serosanguineous drainage on dressing. Dressing is intact. Client reports pain as 5 on a scale of 0 to 10. Lung sounds are diminished in posterior lobes. Bowel sounds are hypoactive in all 4 quadrants. Last bowel movement was this morning.
1730:
Client is restless and short of breath. Reports pain as 8 on a scale of 0 to 10. Pain medication administered.
Vital Signs
1730:
- Temperature 37.2° C (98.9° F)
- Blood pressure 168/84 mm Hg
- Heart rate 116/min
- Respiratory rate 24/min
- Oxygen saturation 93% on room air
a small amount of serosanguineous drainage
Lung sounds are diminished in posterior lobes
pain as 5 on a scale of 0 to 10
Blood pressure 168/84 mm Hg
Respiratory rate 24/min
Oxygen saturation 93% on room air
Bowel sounds are hypoactive in all 4 quadrants
The Correct Answer is ["A","B","C","D"]
a small amount of serosanguineous drainage,
Lung sounds are diminished in posterior lobes,
pain as 8 on a scale of 0 to 10,
Blood pressure 168/84 mm Hg
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Injecting air into the short-acting insulin vial is the first action to be taken. When mixing short-acting and intermediate-acting insulins in the same syringe, the first step is to inject air into the short-acting insulin (clear) vial. This helps equalize the pressure within the vial, making it easier to withdraw the correct dose of insulin
Choice B reason:
Drawing up the desired dose of intermediate-acting insulin into the same syringe is incorrect because it is the last step to be taken.
Choice C reason:
Drawing up the desired dose of short-acting insulin into the syringe is incorrect because it is the third step to be taken.
Choice D reason:
Inject air into the intermediate-acting insulin (cloudy) vial is incorrect because it is the second step to be taken
Correct Answer is B
Explanation
Choice A reason:
Evaluating the healing of an incision is not necessary because it involves clinical judgment and assessment skills, which are generally beyond the scope of practice for assistive personnel.
Choice B reason:
Changing IV tubing is a task that can often be safely delegated to an assistive personnel (AP) who has been trained and deemed competent to perform this task. It is within the AP's scope of practice and doesn't require clinical judgment or assessment.
Choice C reason:
Performing a simple dressing change involves direct contact with a wound and requires knowledge of aseptic technique and wound care principles. This task is typically performed by licensed nursing personnel.
Choice D reason:
Inserting an NG tube is a complex procedure that requires specialized training and skill. It should be performed by a licensed nurse or another healthcare professional with the appropriate training and competence.
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