A registered nurse is providing ongoing post-operative care to a client who has had knee surgery. The nurse assesses the surgical dressing and finds it saturated with blood. The client is restless and has a rapid pulse.
What should the nurse do next?
Make assessments every 15 minutes for four hours.
Document the data, remove the old dressing and apply a new dressing.
Apply a well-secured additional pressure dressing and report findings.
Reassure the family that this is a common problem.
The Correct Answer is C
Rationale for Choice A:
Making assessments every 15 minutes for four hours does not directly address the immediate concern of blood loss and potential hemodynamic instability. While close monitoring is essential, it's not the primary action in this situation.
Excessive blood loss can rapidly lead to hypovolemic shock, which requires prompt intervention to prevent serious complications.
Relying solely on frequent assessments without active interventions could delay crucial treatment and compromise patient safety.
Rationale for Choice B:
Documenting the data, removing the old dressing, and applying a new dressing might be necessary at some point, but it's not the most urgent priority in this case.
Removing the dressing could disrupt clot formation and potentially worsen bleeding.
Applying a new dressing without addressing the underlying bleeding might not effectively control the blood loss. Rationale for Choice C:
Applying a well-secured additional pressure dressing is the most appropriate immediate action to help control bleeding and prevent further blood loss.
It provides direct compression to the surgical site, promoting hemostasis and reducing blood flow. This action prioritizes stabilizing the patient's condition and preventing further complications.
Reporting the findings to the healthcare provider is crucial for timely assessment, diagnosis, and management of potential complications, such as hemorrhage or hematoma.
It ensures collaboration with the healthcare team and facilitates appropriate interventions based on the patient's specific needs.
Rationale for Choice D:
Reassuring the family that this is a common problem might provide some comfort, but it doesn't address the patient's immediate needs or the potential severity of the situation.
It's essential to prioritize patient safety and provide interventions to control bleeding, even if bleeding is a known potential complication.
Transparency and clear communication with the family are important, but they should not replace necessary medical interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale for Choice A:
While it's true that a urinalysis can confirm the eradication of bacteria, it's not routinely recommended in uncomplicated UTIs when symptoms have resolved.
Conducting a urinalysis at this point could potentially lead to unnecessary healthcare visits and costs.
It's important to prioritize patient adherence to the full course of antibiotics, as this is the most effective way to prevent recurrence of infection.
Rationale for Choice B:
This response is inaccurate and could discourage the patient from completing the treatment.
It's essential for the nurse to convey that the treatment is likely working, even though the patient is feeling better. Reinforcing the importance of completing the full course of antibiotics is crucial for optimal outcomes. Rationale for Choice C:
Stopping the antibiotic prematurely, even if symptoms have improved, can lead to:
Increased risk of recurrent UTI
Development of antibiotic resistance
Prolonged or more severe infections in the future
Completing the full course of antibiotics ensures that all bacteria are eradicated, reducing the likelihood of these complications.
Rationale for Choice D:
This response correctly emphasizes the importance of completing the full course of antibiotics, even when symptoms have resolved.
It addresses the patient's concern while providing accurate and essential information.
Key points to highlight in this response include:
The need to eliminate all bacteria, including those that may not be causing active symptoms
The prevention of antibiotic resistance
The reduction of the risk of recurrent UTIs
Correct Answer is C
Explanation
Choice A rationale:
The physical dimension addresses the body's biological and physiological systems, such as organs, tissues, and cells. It does not directly relate to seeking support from others.
While the mother's actions may indirectly impact her child's physical health by reducing stress and potentially improving asthma management, the primary focus of her behavior is social connection and support, not physical interventions.
Choice B rationale:
The intellectual and spiritual dimension encompasses a person's thoughts, beliefs, values, and sense of purpose. While seeking support can involve sharing thoughts and beliefs, the mother's primary motivation is likely to connect with others who share similar experiences, rather than to explore intellectual or spiritual aspects of asthma.
Choice C rationale:
The socio-cultural dimension involves the social and cultural factors that influence a person's health and well-being. This includes:
Relationships with family, friends, and community
Cultural beliefs and practices
Social norms and expectations
Access to resources and support systems
The mother's desire to connect with other parents of children with asthma clearly demonstrates the influence of social relationships and shared experiences on her coping and support-seeking behavior.
This aligns with the concept of social support, which has been shown to have significant benefits for both physical and mental health.
Choice D rationale:
The environmental dimension refers to the physical and social surroundings that affect a person's health. While the environment can play a role in asthma management (e.g., exposure to allergens), it is not the primary focus of the mother's actions in seeking support from other parents.
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