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
Choice A rationale:
Reduced kidney ability to concentrate urine is a common physiological change associated with normal aging. This is due to several factors, including:
Decreased glomerular filtration rate (GFR): The kidneys filter waste products from the blood. As we age, the number of functioning nephrons (filtering units) in the kidneys decreases, leading to a decline in GFR. This means that the kidneys are less able to filter waste products and concentrate urine.
Decreased renal blood flow: Blood flow to the kidneys also decreases with age. This further reduces the kidneys' ability to filter waste products and concentrate urine.
Decreased tubular function: The tubules in the kidneys are responsible for reabsorbing water and electrolytes from the urine. As we age, the function of the tubules also declines, leading to a decrease in the ability to concentrate urine.
As a result of these changes, older adults often produce more urine, even at night. This can lead to nocturia, which is the need to wake up to urinate two or more times per night.
Choice B rationale:
Lower fluid intake during daytime hours can also contribute to nocturia, but it is not a direct physiological change associated with normal aging. Older adults may drink less fluids during the day for a variety of reasons, such as decreased thirst sensation, fear of incontinence, or limited access to fluids. However, even if they maintain adequate fluid intake during the day, they may still experience nocturia due to the reduced ability of their kidneys to concentrate urine.
Choice C rationale:
Enhanced bladder contractility leading to urinary stasis is not a typical physiological change associated with normal aging. In fact, bladder contractility often decreases with age, which can lead to difficulty emptying the bladder completely. This can contribute to urinary frequency and urgency, but it is not typically a cause of nocturia.
Choice D rationale:
Increased bladder muscle tone leading to frequent urination is also not a typical physiological change associated with normal aging. Bladder muscle tone may decrease with age, which can lead to difficulty emptying the bladder completely. However, it is not typically a cause of nocturia.
Correct Answer is ["B","C","E"]
Explanation
A. Pale, yellow urine: While pale yellow urine can be a symptom of a UTI, it is not specific enough and can be caused by other factors like dehydration or certain medications. Therefore, it is not a reliable indicator of a UTI in this case.
B. Cloudy urine: Cloudy urine is a more specific symptom of a UTI, as it can indicate the presence of white blood cells or bacteria in the urine. This finding, along with other symptoms, suggests a possible UTI.
C. Suprapubic pain: Suprapubic pain, which is pain felt above the pubic bone in the lower abdomen, is a common symptom of bladder infections, including UTIs. This finding is highly suggestive of a UTI in this client.
D. Temperature of 38.2 C (100.7 F): Although fever can be a symptom of a UTI, it is not always present and can be caused by other infections or conditions. Therefore, a single elevated temperature, without other supporting symptoms, is not conclusive for a UTI diagnosis.
E. Constant urge to urinate (dysuria): Dysuria, or a frequent and urgent need to urinate, is another common symptom of UTIs. This finding, along with cloudy urine and suprapubic pain, further strengthens the suspicion of a UTI in this client.
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