An older adult resident calls the practical nurse (PN) to the room in a long-term care facility. The resident reports an episode of vomiting and shows the PN the contents of the emesis basin. The PN observes the emesis. Which action is most important for the PN to take?
Notify the nursing supervisor of the appearance of the emesis.
Advise the client to report any further vomiting to the PN.
Determine if the client has a PRN prescription for an antiemetic.
Assign an unlicensed assistive personnel to provide mouth care.
The Correct Answer is A
A. Notify the nursing supervisor of the appearance of the emesis:
Coffee-ground emesis indicates upper GI bleeding; requires prompt reporting for evaluation and intervention.
B. Advise the client to report any further vomiting to the PN:
Appropriate for minor issues, but not for potentially serious GI bleed.
C. Determine if the client has a PRN prescription for an antiemetic:
Masking symptoms with antiemetics without addressing cause can delay diagnosis.
D. Assign an unlicensed assistive personnel to provide mouth care:
Comfort measure, but secondary to urgent assessment and provider notification.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Infusion pump and IV site: Necessary but not priority for safety during epidural initiation.
B. Level of pain sensation: Important for effectiveness but not as urgent as monitoring for hypotension.
C. Maternal blood pressure (BP): Epidural anesthesia can cause vasodilation and maternal hypotension, which can compromise fetal oxygenation.
D. Variability of fetal heart rate: Important but affected indirectly by maternal BP; BP is assessed first.
Correct Answer is C
Explanation
A. Start at the most inflamed area to protect the tissue and promote healing:
Cleansing should progress from least contaminated to most contaminated area.
B. Start at the area with the most drainage to avoid infecting other areas:
This would spread bacteria to cleaner tissue.
C. Start at the drain site to avoid bringing skin bacteria toward the wound:
Drain site is most contaminated; clean outward to prevent contamination of wound.
D. Start at the clean area several inches away from the drain to avoid contaminating the drain:
Would push bacteria toward the more vulnerable drain site.
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