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The practical nurse (PN) receives change of shift report on a postpartum unit. Which client should receive the PN's attention first?

A.

A client who needs to ambulate to the bathroom for the first time since the birth of her infant.

B.

A client prepared for discharge who has a question about the teaching she received the day before.

C.

A client with twins who is tired and would like her babies returned to the newborn nursery.

D.

A post cesarean client with a prescription to have her indwelling urinary and intravenous

Answer and Explanation

The Correct Answer is A

A. A client who needs to ambulate for the first time since delivery requires the PN’s immediate attention to ensure safety and prevent complications such as orthostatic hypotension or falls.
B. A client prepared for discharge who has a question about teaching is important but does not take precedence over immediate safety concerns related to the client’s physical activity.
C. A tired client with twins who would like her babies returned to the nursery is important for the client’s well-being, but it is not as urgent as ensuring the safety of a postpartum client beginning to ambulate.
D. Removing indwelling urinary and intravenous catheters is important but not as urgent as ensuring the safety of a client ambulating for the first time after birth.
 


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Related Questions

Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"F","dropdown-group-3":"D"}

Explanation

  1. Dark Room Lighting
    Consistent with Elder Mistreatment: A dark, uninviting environment can indicate neglect or lack of proper care. It may reflect poor living conditions or neglect of the client's environment, which can be a sign of mistreatment.
  2. Malnutrition
    Consistent with Elder Mistreatment: The client’s low weight (98 lb) relative to her height (5 ft 4 in) suggests potential malnutrition. Malnutrition can be a sign of neglect, as the client might not be receiving adequate food or nutrition, which is a form of mistreatment.
  3. Pressure Injuries
    Consistent with Elder Mistreatment: Although the pressure injuries have closed, the presence of Stage II pressure ulcers in the past indicates a lack of proper care and attention to the client’s needs. Pressure ulcers are a common sign of neglect in care settings.

Not Consistent with Elder Mistreatment

  • Poor Hygiene
    Not Consistent: The client appears clean and healthy with no issues in skin condition or oral hygiene, so this is not a sign of mistreatment.
  • Bilateral Leg Edema
    Not Consistent: While edema might be a concern in heart failure management, it is not specifically indicative of elder mistreatment.
  • Short Term Memory Loss
    Not Consistent: Short-term memory loss is not necessarily a sign of mistreatment; it could be related to aging or medical conditions.

Correct Answer is B

Explanation

A. Measure urinary output.
Measuring urinary output is important for monitoring fluid balance but is not the most critical intervention for assessing left-sided heart failure specifically.
B. Auscultate all lung fields.
Auscultating lung fields is crucial for assessing signs of pulmonary edema, a key symptom of left-sided heart failure. It provides direct information about the severity of the condition and guides further management.
C. Check mental acuity.
Checking mental acuity can be useful but is not the most critical intervention for managing left-sided heart failure. It is less directly related to evaluating the severity of heart failure compared to lung auscultation.
D. Inspect for sacral edema.
Inspecting for sacral edema is more relevant for right-sided heart failure. For left-sided heart failure, the priority is evaluating pulmonary symptoms, not peripheral edema.

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