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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.

A.

Respiratory rate 18 breaths/minute

B.

Heart rate 101 beats/minute

C.

Capillary refill 2 seconds

D.

Breath sounds clear and equal bilaterally

E.

Turban dressing is saturated with serosanguinous drainage

F.

Blood pressure 140/84 mm Hg

G.

Temperature 101.9° F (38.8° C)

H.

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
 


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Related Questions

Correct Answer is ["C","D"]

Explanation

A. Teaching the client with fluid restrictions how to measure urine output requires specialized knowledge and skills. This task should be performed by a licensed nurse to ensure accurate instruction and patient understanding.
B. Irrigating an indwelling urinary catheter involves sterile technique and specialized knowledge, which should be performed by a licensed nurse. This task requires specific training to prevent complications.
C. Transporting a urine culture sample to the laboratory can be safely assigned to a UAP. It involves routine tasks that do not require advanced clinical skills and is essential for timely processing of specimens.
D. Emptying the bedside drainage unit for a client with an indwelling urinary catheter can be performed by a UAP. This task involves basic care procedures that support patient hygiene and comfort.
E. Obtaining a post-voided residual (PVR) volume requires a specific clinical skill and understanding of the procedure, which should be performed by a licensed nurse rather than a UAP.

Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"E","dropdown-group-3":"D"}

Explanation

  1. Dark Room Lighting
    Consistent with Elder Mistreatment: A dark, uninviting environment can indicate neglect or lack of proper care. It may reflect poor living conditions or neglect of the client's environment, which can be a sign of mistreatment.
  2. Malnutrition
    Consistent with Elder Mistreatment: The client’s low weight (98 lb) relative to her height (5 ft 4 in) suggests potential malnutrition. Malnutrition can be a sign of neglect, as the client might not be receiving adequate food or nutrition, which is a form of mistreatment.
  3. Pressure Injuries
    Consistent with Elder Mistreatment: Although the pressure injuries have closed, the presence of Stage II pressure ulcers in the past indicates a lack of proper care and attention to the client’s needs. Pressure ulcers are a common sign of neglect in care settings.

Not Consistent with Elder Mistreatment

  • Poor Hygiene
    Not Consistent: The client appears clean and healthy with no issues in skin condition or oral hygiene, so this is not a sign of mistreatment.
  • Bilateral Leg Edema
    Not Consistent: While edema might be a concern in heart failure management, it is not specifically indicative of elder mistreatment.
  • Short Term Memory Loss
    Not Consistent: Short-term memory loss is not necessarily a sign of mistreatment; it could be related to aging or medical conditions.

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