After receiving report, the nurse can most safely plan to assess which client last?
An adult client with a tracheal tube draining clear, pale red liquid drainage
An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac.
An adult client with no postoperative drainage in the Jackson-Pratt drain with the bulb compressed.
An older client with a distended abdomen and no drainage from the nasogastric tube.
The Correct Answer is C
Choice A: An adult client with a tracheal tube draining clear, pale red liquid drainage. This client should not be assessed last, as they may have a potential airway obstruction or infection. The tracheal tube drainage should be monitored for color, amount, and consistency, and suctioned as needed.
Choice B: An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac. This client should not be assessed last, as they may have a potential hemorrhage or wound dehiscence. The postoperative dressing and Hemovac should be monitored for color, amount, and odor, and changed as needed.
Choice C: An adult client with no postoperative drainage in the Jackson-Pratt drain with the bulb compressed. This client can be assessed last, as they have no signs of complications or problems. The Jackson-Pratt drain is a closed suction device that collects fluid from a surgical site. The bulb should be compressed to create negative pressure and facilitate drainage.
Choice D: An older client with a distended abdomen and no drainage from the nasogastric tube. This client should not be assessed last, as they may have a potential bowel obstruction or perforation. The nasogastric tube is inserted through the nose into the stomach to decompress gas and fluid. The abdomen should be monitored for size, shape, and bowel sounds, and the nasogastric tube should be checked for patency and placement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A is correct because a distended bladder can displace the uterus and prevent it from contracting properly, leading to increased bleeding and risk of infection. The nurse should check for a distended bladder and assist the client to empty it if needed.
Choice B is incorrect because reviewing the hemoglobin is not a priority action. The hemoglobin may not reflect the current blood loss and may be done later.
Choice C is incorrect because massaging the uterus is not necessary if it is firm. Massaging a firm uterus can cause overstimulation and pain.
Choice D is incorrect because increasing intravenous infusion is not a priority action. The client may not need additional fluids if the bleeding is moderate and the vital signs are stable.
Correct Answer is A
Explanation
Choice B reason: Arranging diet schedule around three regular meals a day is not a sufficient point for disease and symptom management for a client with type 2 diabetes mellitus. Diabetes mellitus is a condition that affects the body's ability to produce or use insulin, a hormone that regulates blood glucose levels. Eating three regular meals a day may not be enough to control blood glucose levels and prevent complications such as hypoglycemia or hyperglycemia. The nurse should teach the client to follow a balanced diet that includes carbohydrates, proteins, fats, vitamins, minerals, and fiber, and to eat smaller portions more frequently throughout the day.
Choice C reason: Using garlic, herbs, and spices will improve the flavor of food is not a specific point for disease and symptom management for a client with type 2 diabetes mellitus. Garlic, herbs, and spices are natural ingredients that can enhance the taste and aroma of food, but they do not have a direct impact on blood glucose levels or diabetes complications. The nurse should teach the client to limit the intake of salt, sugar, and saturated fats, and to choose foods that are low in glycemic index and high in antioxidants.
Choice D reason: Inspecting feet every month for ingrown nails, cuts, and calluses is not a frequent enough point for disease and symptom management for a client with type 2 diabetes mellitus. Diabetes mellitus can cause damage to the blood vessels and nerves in the feet, leading to reduced sensation, poor circulation, infection, ulceration, and amputation. The nurse should teach the client to inspect feet every day for any signs of injury or infection, and to wash, dry, moisturize, and protect them properly. The nurse should also advise the client to wear comfortable shoes and socks, avoid walking barefoot, and seek medical attention for any foot problems.
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