A nurse is providing ongoing postoperative care to a client who has had knee surgery. The nurse assesses the dressing and finds it saturated with blood. The client is restless and has a rapid pulse. What should the nurse do next?
Reassure the family that this is a common problem.
Apply a pressure dressing and report findings.
Document the data and apply a new dressing.
Make assessments every 15 minutes for 4 hours.
The Correct Answer is B
A. Reassuring the family without addressing the issue is unsafe.
B. Applying a pressure dressing helps control bleeding, and reporting findings promptly ensures timely medical intervention.
C. Simply documenting and changing the dressing without addressing bleeding risks worsening the condition.
D. Waiting to monitor without immediate intervention could allow the client’s condition to deteriorate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While loneliness can contribute to distress, the specific behaviors observed (excessive religious reading, crying, and poor sleep) suggest something deeper than just social isolation.
B. These behaviors are signs of spiritual distress, which may occur when a person is facing a serious illness or surgery and is struggling with questions of meaning, faith, or fear. Spiritual distress can manifest emotionally and behaviorally, as seen here.
C. While some anxiety is expected before major surgery, persistent emotional signs like excessive crying and poor sleep, along with intense religious focus, indicate more than normal preoperative nerves.
D. Labeling the client as “naturally emotional” is an assumption and dismisses the need for assessment and appropriate support.
Correct Answer is A
Explanation
A. Incontinence and infrequent changing of adult diapers increase the risk of altered skin integrity, such as skin breakdown or pressure ulcers, due to prolonged exposure to moisture and irritation.
B. The Answer seems incomplete ("risk") and does not specify the type of risk.
C. Activity intolerance is not directly related to incontinence or diaper use.
D. While falls risk is important in older adults, it is not the primary concern related to incontinence and diaper changing.
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