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. Transcription of the healthcare provider's treatment plan for a client transferred from a critical care unit. B. The subclavian dressing change on a client diagnosed with inflammatory bowel disease. C. The admission assessment of a client diagnosed with bacterial pneumonia. D. The insertion of a Foley catheter for a client diagnosed with septicemia.

Correct Answer is D

Explanation

Choice A reason: Transcription of the healthcare provider's treatment plan is not a task that can be delegated to a PN, as it requires nursing judgment and documentation. The charge nurse should perform this task and verify the orders with the provider.

Choice B reason:A subclavian catheter dressing change is a sterile procedure involving central line care, which is considered an advanced skill typically performed by an RN. Many facilities do not allow PNs to perform this due to the risk of infection and complications.

Choice C reason: The admission assessment is not a task that can be delegated to a PN, as it involves collecting and analyzing data from multiple sources. The charge nurse or the registered nurse should perform this task and document the findings.

Choice D reason: PNs are trained and authorized to insert Foley catheters, which is within their scope of practice. Although the patient has septicemia, catheter insertion is a task-based procedure that does not require critical decision-making, making it an appropriate assignment for a PN.

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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

The charge nurse, working with one nurse, two practical nurses (PNs), a unit secretary, and two unlicensed assistive personnel (UAPs), is caring for 24 clients on a medical surgical unit. Which task is best for the charge nurse to assign to the PN?

Correct Answer is D

Explanation

When triaging emergency room clients, which client should the nurse assess first?

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?

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

The nurse-manager overhears an older female nurse complaining to a co-worker about the time being used to attend an in-service session for bioterrorism preparedness. How should the nurse-manager respond?

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?