The practical nurse (PN) finds a postoperative client lying in bed with an unsecured surgical dressing as seen in the picture. After reinforcing the dressing, which follow-up assessment is most important for the PN to implement?
Vital sign measurement.
Fluid volume intake and output.
Volume of peripheral pulses.
Incisional pain scale rating.
The Correct Answer is A
This is the most important follow-up assessment for the PN to implement because it can detect signs of bleeding, infection, or shock that may result from the unsecured surgical dressing. The PN should monitor the client's blood pressure, pulse, temperature, and respiratory rate and report any abnormal changes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is the group of children that the PN should screen for scoliosis because they are at the highest risk of developing this condition. Scoliosis is a lateral curvature of the spine that usually occurs during the growth spurt before puberty. Girls are more likely than boys to have scoliosis, and the condition tends to worsen during adolescence.
A. High school boys are not at high risk of scoliosis and do not need to be screened unless they have signs or symptoms of the condition.
B. High school girls are at lower risk of scoliosis than middle school girls because they have completed most of their growth spurt and their condition is less likely to progress.
C. Middle school boys are at lower risk of scoliosis than middle school girls because they have a slower growth rate and a later onset of puberty.
Correct Answer is D
Explanation
Choice A rationale: While it is important to monitor the fetal heart rate, it does not directly address the client's immediate need to empty her bladder.
Choice B rationale: Obtaining a straight catheter kit to empty her bladder could be considered if the client is unable to void on her own, but it is not the first line of action if the client is able to ambulate.
Choice C rationale: Checking the perineum for changes in "show" or discharge is part of ongoing labor monitoring, but it does not address the client's immediate request.
Choice D rationale: Assisting the client up to the bathroom is appropriate. Ambulating to the bathroom is safe given the unchanged vaginal exam, and allowing the client to empty her bladder can help maintain bladder function and comfort.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today