The nurse is planning care for four postoperative clients, each with a different drainage system. Which information, received in report, requires immediate follow-up intervention by the nurse?

30 mL of serous fluid obtained from compression bulb device in last 4 hours.

40 mL per hour of dark, cloudy urine from urinary catheter in last 4 hours.

20 mL of serosanguinous drainage from chest tube in last 8 hours.

No observable drainage from 3-day-old Penrose drain in last 8 hours.

Answer and Explanation

The Correct Answer is D

Choice A reason: 30 mL of serous fluid from a compression bulb device is not a cause for concern. It indicates that the wound is healing and the device is functioning properly.

Choice B reason: 40 mL per hour of dark, cloudy urine from a urinary catheter may indicate dehydration, infection, or hematuria, but it is not an immediate priority. The nurse should monitor the urine output and characteristics, and report any abnormal findings to the provider.

Choice C reason: 20 mL of serosanguinous drainage from a chest tube is expected after thoracic surgery. It reflects the normal inflammatory response and the removal of excess fluid from the pleural space.

Choice D reason: No observable drainage from a 3-day-old Penrose drain is a sign of possible obstruction or infection. The nurse should assess the site for swelling, redness, pain, or purulent drainage, and notify the provider immediately. The Penrose drain should be replaced or removed as soon as possible.

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Correct Answer is A

Explanation

Choice A reason: Calling for an assistant is the best action for the nurse to take. This can help the nurse maintain aseptic technique and ensure the safety of the client undergoing the lumbar puncture, while also allowing the nurse to respond to the code as soon as possible.

Choice B reason: Responding to the code is not the best action for the nurse to take. This may compromise the aseptic technique and the safety of the client undergoing the lumbar puncture, who may also experience complications or adverse reactions.

Choice C reason: Closing the room door is not the best action for the nurse to take. This may isolate the client undergoing the lumbar puncture and prevent the nurse from communicating or receiving assistance from other staff members.

Choice D reason: Finishing the procedure is not the best action for the nurse to take. This may delay the nurse's response to the code and jeopardize the survival of the client experiencing respiratory arrest, who needs immediate and effective resuscitation.

A. Assign the UAP to provide care for another client and assume full care of the client. B. Remind the UAP to apply a fitted respirator mask before entering the client's room. C. Review the need for the UAP to wear a face mask while in close contact with the client. D. Instruct the UAP to notify the nurse of any changes in the client's respiratory status.

Correct Answer is C

Explanation

Choice A reason: Assigning the UAP to provide care for another client and assuming full care of the client is not the best action for the nurse to take. This may disrupt the continuity of care and the rapport between the UAP and the client. It may also be unnecessary and inefficient for the nurse to take over the care of the client.

Choice B reason: Reminding the UAP to apply a fitted respirator mask before entering the client's room is not the best action for the nurse to take. This may be incorrect and inappropriate for the prevention of pertussis transmission. A fitted respirator mask is used for airborne precautions, while pertussis is spread by droplet contact.

Choice C reason: Reviewing the need for the UAP to wear a face mask while in close contact with the client is the best action for the nurse to take. This can educate the UAP about the proper infection control measures for pertussis, which include droplet precautions. A face mask can prevent the UAP from inhaling or spreading the droplets that contain the bacteria.

Choice D reason: Instructing the UAP to notify the nurse of any changes in the client's respiratory status is not the best action for the nurse to take. This may be irrelevant and redundant for the situation. The UAP should already know to report any changes in the client's condition to the nurse, regardless of the diagnosis or the intervention.

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The nurse is planning care for four postoperative clients, each with a different drainage system. Which information, received in report, requires immediate follow-up intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assisting with a lumbar puncture on a client. During the procedure, a code is called for another client on the unit who is experiencing respiratory arrest. Which action should the nurse take?

Correct Answer is A

Explanation

A child is admitted to the pediatric unit after being diagnosed with pertussis. The nurse observes an unlicensed assistive personnel (UAP) donning a pair of gloves before entering the room to give the child a popsicle. Which action should the nurse take?

Correct Answer is C

Explanation

The practical nurse reports that a client with a deep vein thrombosis (DVT) was mistakenly given heparin in addition to the prescribed warfarin. Which priority action should the nurse take?

The nurse is planning care for four postoperative clients, each with a different drainage system. Which information, received in report, requires immediate follow-up intervention by the nurse?

The charge nurse needs to determine if an additional nurse should be called to help staff the unit for the next shift. Which information is most important for the charge nurse to consider when making this decision?

The nurse observes a practical nurse (PN) placing a client on the right side with the left leg bent in preparation for a lumbar puncture. Which action should the nurse implement?

It is most important for the charge nurse to schedule a multi-disciplinary team meeting to discuss which client?

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