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Exhibits

The practical nurse (PN) performs a focused assessment and documents it in the computer. Select what items require immediate follow-up by the PN. Select all that apply.

Respiratory rate 18 breaths/minute

Heart rate 101 beats/minute

Capillary refill 2 seconds

Breath sounds clear and equal bilaterally

Turban dressing is saturated with serosanguinous drainage

Blood pressure 140/84 mm Hg

Temperature 101.9° F (38.8° C)

Client is awake and alert

Answer and Explanation

Correct Answer : B,E,G

A. Respiratory rate 18 breaths/minute
The respiratory rate is within the normal range for an adult (12-20 breaths/minute). No immediate follow-up is required for this vital sign.
B. Heart rate 101 beats/minute
An elevated heart rate (tachycardia) can indicate several issues, including fever, infection, or pain. In the context of a surgical site infection and elevated temperature, tachycardia is a sign of systemic response and needs to be evaluated further to determine the cause and appropriate intervention.
C. Capillary refill 2 seconds
Capillary refill time of 2 seconds is within the normal range (≤ 2 seconds) and indicates adequate perfusion. No immediate follow-up is needed.
D. Breath sounds clear and equal bilaterally
This finding indicates no acute respiratory issues. No immediate follow-up is necessary based on this assessment.
E. Turban dressing is saturated with serosanguinous drainage
Saturation of the dressing with serosanguinous drainage indicates a significant amount of wound drainage, which could suggest worsening of the infection or a new complication. This finding requires immediate follow-up to assess the wound and determine if additional interventions or changes in treatment are necessary.
F. Blood pressure 140/84 mm Hg
While slightly elevated, this blood pressure reading is not excessively abnormal and does not require immediate follow-up in the absence of other symptoms. Monitoring is required but not urgent.
G. Temperature 101.9° F (38.8° C)
An elevated temperature indicates a fever, which is a sign of infection. Given the positive MRSA culture and the need for infection control, this temperature warrants immediate follow-up to assess for worsening infection and determine the need for antipyretics or antibiotics.
H. Client is awake and alert
Being awake and alert is a positive finding and does not require immediate follow-up

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Understanding that prostate cancer mostly affects older men reflects awareness but does not necessarily indicate acceptance of the prognosis.
B. Expressing that the client has found support from faith and family and rejecting negative outlooks shows a level of emotional acceptance and coping with the reality of advanced cancer.
C. Believing that the disease was undetected for a long time suggests denial or frustration rather than acceptance of the prognosis.
D. A desire to try every possible treatment reflects hope and possibly denial rather than acceptance of the prognosis.

A. Move away from the overbed table. B. Pull glove down, keeping inside out. C. Loosen the glove from the fingers. D. Raise the hands above waist level.

Correct Answer is B

Explanation

A. Move away from the overbed table: This action can be done after the gloves are completely removed and disposed of. Moving away too early increases the risk of bumping into something and contaminating the gloves.
B. Sterile gloves are contaminated on the outside after performing a procedure like a dressing change. Pulling the glove down and everting it (turning it inside out) confines the contamination to the inside of the glove, reducing the risk of transferring germs to the hands or surrounding surfaces. This maintains a sterile field and minimizes the risk of healthcare-associated infections (HAIs).
C. Loosen the glove from the fingers: This might be the initial step while grasping the glove for removal, but the key is to maintain aseptic technique by keeping the outside of the glove contained throughout removal.
D. Raise the hands above waist level: Raising hands above the waist level increases the risk of contaminating the sterile field or nearby surfaces if the glove integrity is compromised.

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Exhibits The practical nurse (PN) performs a focused assessment and documents it in the computer. Select what items require immediate follow-up by the PN. Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement by a mature adult client with advanced prostate cancer best indicates that he has reached a level of acceptance of his prognosis?

Correct Answer is B

Explanation

As seen in the picture, the practical nurse (PN) begins to remove a pair of sterile gloves after changing a client's dressing. Which action should the PN take next?

Correct Answer is B

Explanation

A client who is experiencing paralysis of the left arm curses at the practical nurse (PN) and throws a hairbrush against the wall using the right arm. How should the PN respond?

A client who had a knee replacement surgery receives a prescription for enoxaparin 30 mg subcutaneously every 12 hours for 10 days. The medication is available in 30 mg per 0.3 mL prefilled syringes. How many mL should the practical nurse (PN) administer each day? (Enter numerical value only.)

Exhibits The practical nurse (PN) is preparing to change the turban dressing. For each intervention, click to indicate whether it is indicated or not indicated for the dressing change. Each row must have one

When the practical nurse (PN) attempts to assist an 18-year-old client with a mild mental disability to ambulate on the first postoperative day after an appendectomy, she becomes angry and yells at the PN, "Get out of here! I'll get up when I'm ready!" Which response is best for the PN to make?

An older adult client who had a colon resection 8 days ago is straining at stool. The practical nurse (PN) observes sudden spillage of serosanguinous drainage from the client's wound followed by appearance of bowel on the skin. Which complication has occurred?

Which location should the practical nurse (PN) palpate to determine if a client's submandibular lymph nodes are enlarged?

Exhibits The practical nurse (PN) performs a focused assessment and documents it in the computer. Select what items require immediate follow-up by the PN. Select all that apply.

Exhibits

The practical nurse (PN) performs a focused assessment and documents it in the computer. Select what items require immediate follow-up by the PN. Select all that apply.