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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Maternal hypotension is a significant adverse effect of epidural anesthesia that can lead to decreased uterine blood flow and fetal distress. Monitoring for hypotension is critical to ensure both maternal and fetal well-being.
B. While a vaginal hematoma is a potential complication, it is less immediately associated with the administration of epidural anesthesia compared to hypotension.
C. A continuous headache could indicate post-dural puncture but is less common and not the primary immediate concern compared to hypotension following an epidural.
D. Urinary retention can occur with epidural anesthesia, but maternal hypotension is a more urgent and significant immediate concern.
Correct Answer is D
Explanation
A. Assigning the UAP to more stable clients does not address the immediate issue of the protocol omission and does not ensure that the protocol is followed correctly in the future.
B. Completing an unusual occurrence report is not necessary if the omission was corrected and the situation does not involve a significant error or safety issue.
C. Reporting to the charge nurse may be appropriate, but the priority is to ensure the UAP understands and follows the protocol, which is best achieved through direct supervision.
D. Supervising the UAP and reviewing the protocol ensures that the UAP understands and adheres to the fall prevention protocol moving forward, addressing both the immediate issue and future adherence.
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