After the change-of-shift report, the practical nurse (PN) makes rounds on a postoperative unit. Which client finding necessitates the Immediate attention of the PN?
An older client whose blood pressure (BP) is 100/70 after receiving meperidine for pain related to a hip fracture.
A client who has pink urine draining from the indwelling urinary catheter following transurethral prostatectomy.
A client who is having bright red drainage from the rectum following a colonoscopy with polyp removal.
A client who has brown-green bile draining from a T-tube after cholecystectomy for cholelithiasis.
The Correct Answer is C
The client finding that necessitates immediate attention by the practical nurse (PN) is a client who is having bright red drainage from the rectum following a colonoscopy with polyp removal. Bright red rectal bleeding can indicate active bleeding and immediate intervention is required to assess the severity of the bleeding, control the bleeding if possible, and prevent further complications.
A. The older client with a blood pressure of 100/70 after receiving meperidine for pain may require further assessment, but it does not indicate an immediate life-threatening condition.
B. Pink urine draining from the indwelling urinary catheter following a transurethral prostatectomy may be expected due to the surgical procedure, but it should still be monitored.
D. Brown-green bile draining from a T-tube after cholecystectomy for cholelithiasis is also an expected finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
While all of the options address the issue of impaired mobility related to fear of falling, the desired outcome of ambulating with assistance q4 hours is the most specific and measurable goal. This outcome focuses on promoting mobility and addressing the client's fear of falling by providing the necessary assistance during ambulation. It ensures that the client is engaging in regular activity and working towards regaining mobility.
The other options address different aspects of the nursing problem:
A. "The client will use self-affirmation statements to decrease fear" is a potential intervention that can be used to address the client's fear of falling, but it does not directly address the issue of impaired mobility.
C. "The physical therapist will instruct the client in the use of a walker" is an intervention that can be helpful in improving mobility, but it does not specify the frequency or timing of ambulation.
D. "The PN will place a gait belt on the client prior to ambulation" is a specific intervention that ensures the safety of the client during ambulation, but it does not address the frequency or timing of ambulation.
Correct Answer is ["C","E"]
Explanation
C. Regularly selects salty snacks to eat in the evening: Consuming excessive amounts of sodium (found in salty snacks) can increase blood pressure and contribute to the development of hypertension.
E. Chews tobacco while playing baseball every weekend: Tobacco use, including chewing tobacco, is associated with an increased risk of hypertension and other cardiovascular diseases.
The other choices are incorrect because they do not directly contribute to an increased risk of hypertension:
A. Drinks a protein supplement for breakfast every day: Consuming a protein supplement for breakfast does not necessarily increase the risk of hypertension. However, it is important to note that some protein supplements may contain added sodium, which can contribute to hypertension if consumed in excessive amounts.
B. Eats eight ounces of nonfat yogurt for lunch daily: Eating nonfat yogurt is generally considered a healthy food choice. However, unless the yogurt is high in added sodium, it would not significantly increase the risk of hypertension.
D. Walks briskly for two miles every day after work: Regular exercise, such as brisk walking, is generally beneficial for cardiovascular health and can help lower blood pressure. It is unlikely to increase the risk of hypertension.
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