The practical nurse (PN) is caring for a client recovering from abdominal surgery. Which action should the PN take first?
Order supplies for a dressing change.
Monitor cardiorespiratory status.
Assess the client's pain level.
Provide an incentive spirometer.
The Correct Answer is B
A. Order supplies for a dressing change: Obtaining supplies is part of routine postoperative care but is not the first priority. Before any intervention, the PN must ensure the client’s vital functions, airway, breathing, and circulation, are stable.
B. Monitor cardiorespiratory status: Following abdominal surgery, the greatest immediate risk is respiratory compromise due to anesthesia, pain, or immobility. Monitoring the client’s breathing and cardiac function is the first priority to detect hypoxia, respiratory depression, or hemodynamic instability early.
C. Assess the client’s pain level: Pain assessment is important for comfort and to encourage deep breathing and mobility. However, cardiorespiratory monitoring takes precedence, as it ensures life-sustaining stability before addressing discomfort.
D. Provide an incentive spirometer: Promoting lung expansion is beneficial in preventing postoperative atelectasis, but the PN must first confirm adequate respiratory status before instructing or assisting with incentive spirometry.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Pain scale: Postherpetic neuralgia, persistent nerve pain following shingles, is a common complication. Assessing pain intensity, quality, and location helps guide pain management and evaluate recovery, making it the most critical data to obtain.
B. Capillary refill: Capillary refill assesses peripheral perfusion but is not directly affected by shingles or its treatment, making it less relevant for a focused post-shingles assessment.
C. Joint mobility: While joint mobility is important in general health assessments, shingles typically does not impair joint function. Monitoring mobility is not the priority in this context.
D. Urine color: Urine color is unrelated to shingles or its treatment in most cases. Assessing it does not provide essential information for evaluating post-shingles recovery.
Correct Answer is C
Explanation
A. The percent of processed or canned foods eaten: Processed and canned foods are typically high in sodium, which would more likely lead to hypernatremia, not hyponatremia. Therefore, this information does not help determine the cause of a low sodium level.
B. The number of vegetable servings consumed daily: Vegetable intake has minimal impact on serum sodium levels unless accompanied by excessive fluid intake or specific medical conditions. This question does not directly address possible dilutional or sodium-loss causes.
C. The amount of ice chips and water consumed daily: Excessive intake of water or ice chips can lead to dilutional hyponatremia by lowering serum sodium concentration. Assessing fluid consumption is essential to determine if overhydration is contributing to the client’s low sodium level.
D. The amount of salt substitute used in meal preparation: Many salt substitutes contain potassium instead of sodium, which may alter potassium levels but not directly explain hyponatremia. The primary focus should be on identifying fluid-related factors rather than sodium replacement products.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.