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 A
Explanation
Urinary retention is the inability to completely empty the bladder. It is a common symptom of BPH, as the enlarged prostate can press on the urethra and obstruct the flow of urine. This can lead to several characteristic symptoms, including:
Feeling of incomplete bladder emptying: Patients often feel as though they haven't fully emptied their bladder, even after urinating.
Straining to urinate: It may take extra effort to initiate and maintain a urine stream.
Weak urine stream: The force of the urine stream may be noticeably reduced.
Intermittent urine stream: The flow of urine may start and stop repeatedly.
Post-void dribbling: Urine may continue to drip after urination has seemingly ended.
Urinary frequency: The need to urinate frequently, often at night (nocturia).
Urgency: A sudden, compelling need to urinate that may be difficult to postpone.
Bladder pain or discomfort: Pressure or pain in the lower abdomen, often associated with a full bladder. Pathophysiology:
Bladder outlet obstruction: The enlarged prostate physically compresses the urethra, the tube that carries urine from the bladder to the outside of the body. This obstruction makes it difficult for urine to flow freely, leading to incomplete bladder emptying.
Detrusor muscle dysfunction: The detrusor muscle, which forms the bladder wall, may become weakened or overactive due to the constant strain of trying to empty against resistance. This can further impair bladder emptying.
Neurological factors: In some cases, nerve damage or dysfunction may contribute to urinary retention, particularly in men with diabetes or neurological conditions.
Additional insights:
Chronic urinary retention can result in serious complications, such as bladder stones, urinary tract infections, and kidney damage.
Acute urinary retention is a medical emergency that requires immediate catheterization to relieve the bladder and prevent further complications.
Treatment for urinary retention typically involves medications to relax the prostate and bladder muscles, as well as lifestyle modifications such as limiting fluid intake before bedtime. In some cases, surgical intervention may be necessary to reduce the size of the prostate or widen the urethra.
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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