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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A thready pulse is a weak and rapid pulse that is easily obliterated by light pressure. It indicates poor blood ﬂow and perfusion and may be caused by conditions such as shock, dehydration, or hemorrhage.

The other options are not correct because:

B. A missing pulse is a pulse that is absent or cannot be detected, even with firm pressure. It indicates a complete blockage of blood ﬂow, and may be caused by conditions such as arterial occlusion, embolism, or trauma.

C. Light pressure applied to pulse is not a documentation of the pulse quality, but a description of the technique used to palpate the pulse.

D. Pulse skips beats is a documentation of an irregular pulse rhythm, not a pulse volume. It indicates that the heart beats are unevenly spaced, and may be caused by conditions such as arrhythmia, stress, or caﬀeine intake.

A. Clean up and organize the nurses' work-station. B. Verify completion of all new prescriptions. C. Calculate and record intake and output totals. D. Write a narrative shift summary for each client.

Correct Answer is B

Explanation

This is the highest priority task and should be completed first because it ensures the safety and quality of care for the clients. The PN should check that all new prescriptions have been administered, documented, and reported as ordered and that there are no errors or omissions.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) palpates a client's radial pulse and notes that the pulse disappears when light pressure is applied. How should the PN document this finding?

Correct Answer is A

Explanation

The practical nurse (PN) is preparing for shift change. Which task has the highest priority and should be completed first?

Correct Answer is B

Explanation

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