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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 A

Explanation

A. Understanding what the voices are saying is the most important initial step in assessing auditory hallucinations. This information helps the PN gauge the content of the hallucinations, which is crucial for developing a treatment plan and determining the level of risk to the client or others.
B. While knowing when the voices are most disturbing provides useful information for managing symptoms, it is less critical than understanding the content of the hallucinations for developing an initial treatment plan.
C. Assessing how the client copes with the voices is important for ongoing management but comes after understanding what the voices are saying. Coping strategies can be developed based on the nature of the hallucinations.
D. Determining which medication works best is not an immediate priority during the initial assessment. Medication effectiveness will be evaluated over time rather than being a primary focus during the first report of hallucinations.

A. Slide hands under the client's lumbar area and knees. B. Turn the client away from the PN using a turning sheet. C. Put the bed rails up on the opposite side of the bed. D. Grasp the client's hand to pull the client towards the PN.

Correct Answer is B

Explanation

A. Sliding hands under the lumbar area and knees can cause strain on the PN’s back and is not the safest method for turning a dependent client.
B. Using a turning sheet to turn the client away from the PN is the safest method for moving a dependent client, as it uses a proper technique that minimizes injury risk for both the client and the PN.
C. Raising bed rails on the opposite side may increase the risk of injury or falls, and is not directly related to the safe turning of the client.
D. Grasping the client's hand to pull them is unsafe and could cause injury or discomfort to both the client and the PN, especially when turning a dependent client.

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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

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. Which question is most important for the practical nurse (PN) to include in the assessment of this client?

Correct Answer is A

Explanation

The practical nurse (PN) is turning a dependent bedridden client without assistance. Which action will best ensure the client's safety?

Correct Answer is B

Explanation

A newborn's assessment reveals spina bifida occulta. Which maternal factor should the practical nurse (PN) identify as having the greatest impact on the development of this newborn complication?

A client with Parkinson's disease is experiencing decreased postural reflexes, rigidity, retropulsive gait, and shuffling. Which intervention is most important for the practical nurse (PN) to implement?

A client receives a prescription for digoxin 0.25 mg by mouth. The medication is available in 0.125 mg tablets. How many tablets should the practical nurse (PN) administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

While the practical nurse (PN) and unlicensed assistive personnel (UAP) are turning a client with an abdominal incision, the client's incision eviscerates. Which task is best for the PN to assign to the UAP?

An older adult client of a long-term care facility is awake at 0330 and wandering down the hall in unbuttoned pajamas. Which intervention should the practical nurse (PN) implement?

The practical nurse (PN) observes an unlicensed assistive personnel (UAP) obtain a client's vital signs. The PN should intervene when observing the UAP performing which technique?

In implementing the plan of care, which data should the practical nurse (PN) obtain first for a client with a sleep pattern disturbance?

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.