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 B
Explanation
A. The post-voided residual volume assessment is not part of a bladder retraining program but is a diagnostic tool used to assess bladder function after catheter removal. This explanation misrepresents the purpose of the procedure.
B. The post-voided residual volume assessment measures how much urine remains in the bladder after the client has voided. This measurement helps determine if the bladder is emptying properly and whether there is a need for catheter re-insertion.
C. Post-voided residual volume assessment does not stimulate the bladder to empty more completely; instead, it measures the amount of urine left in the bladder. The procedure is diagnostic rather than therapeutic.
D. The post-voided residual volume assessment is a diagnostic procedure, not an exercise in conditioning. This explanation does not accurately describe the clinical purpose of the assessment.
Correct Answer is B
Explanation
A. Isoniazid can cause side effects like peripheral neuropathy, but ringing in the ears is not a common symptom of this medication.
B. Gentamicin can cause ototoxicity, which includes symptoms such as ringing in the ears (tinnitus). This side effect is significant and should be reported to the healthcare provider for further evaluation.
C. Pyridoxine is used to prevent neuropathy caused by isoniazid and does not cause ringing in the ears.
D. Rifampin is an antitubercular medication but is not commonly associated with tinnitus as a side effect. The immediate concern with ringing in the ears is related to gentamicin.
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