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
The correct answer is choice D. Cleanse the finger with soap and water.
Choice A rationale:
Explaining the occurrence to the client is not the first action the PN should take in this situation. The priority is to address the potential exposure to bloodborne pathogens and ensure the PN's safety.
Choice B rationale:
Observing the appearance of the injection site is important for routine assessment but is not the first action the PN should take after getting stuck with the used needle. Immediate action to clean the wound site is essential to reduce the risk of infection.
Choice C rationale:
While notifying the charge nurse about the incident is important, it should not be the first action taken. The PN's safety should be addressed first by cleansing the finger.
Choice D rationale:
The PN should first cleanse the finger with soap and water immediately after getting stuck with the used needle. This action helps reduce the risk of infection and contamination. After cleansing, the PN can follow the facility's protocol for reporting incidents and seek necessary medical attention if required.
Correct Answer is B
Explanation
The correct answer is choice B: Culture for sensitive organisms.
- Choice A rationale:
- C-reactive protein level - C-reactive protein (CRP) is a blood test marker for inflammation in the body. While it could indicate an infection, it is not specific enough to identify the type of infection or the causative organism.
- Choice B rationale:
- Culture for sensitive organisms - When a wound has a moderate amount of yellow and green drainage and a foul odor, it is often a sign of a bacterial infection. A culture for sensitive organisms can help identify the specific bacteria causing the infection, which is crucial for determining the most effective treatment.
- Choice C rationale:
- Serum albumin - Serum albumin levels can indicate a person’s nutritional status. Low levels can slow wound healing, but they do not directly indicate the presence of an infection.
- Choice D rationale:
- Serum blood glucose (BG) level - High blood glucose levels can impair the immune response and slow wound healing, making a person more susceptible to infections. However, like CRP, it does not provide information about the specific organism causing the infection.
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