When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?
Low intermittent suction prescribed for the nasogastric tube is turned off.
A Hemovac drain is partially full of serous drainage and is not compressed.
The urinary catheter drainage bag is almost completely full of amber urine.
Oxygen is being administered via nasal cannula at 4 L/minute without humidification.
None
None
The Correct Answer is D
A. This requires prompt attention but is not immediately life-threatening.
B. This requires attention but does not pose an immediate threat to the client's condition.
C. An almost completely full urinary catheter drainage bag requires attention but does not pose an immediate threat to the client's condition.
D. Administering oxygen without humidification could lead to mucosal dryness and damage, and should be addressed promptly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Monitoring incision drainage is important for infection and wound healing but not directly related to the effectiveness of compression devices.
B. Observing both lower extremities for redness and swelling directly assesses the effectiveness of the pneumatic compression devices in preventing deep vein thrombosis (DVT).
C. Evaluating the use of an incentive spirometer is important for respiratory function but unrelated to the compression devices.
D. Palpating peripheral pulse points is useful for circulation assessment but does not specifically evaluate the prevention of DVT, which is the primary purpose of the compression devices.
Correct Answer is ["A","C","D"]
Explanation
A. Contact precautions are essential to prevent the spread of MRSA to other patients and healthcare workers. This includes wearing gloves and gowns when entering the patient's room.
B. A low bacteria diet is not specifically relevant to managing MRSA and is more applicable to neutropenic patients.
C. Monitoring the white blood cell count helps in assessing the client's response to infection and identifying any potential systemic involvement.
D. Sending wound drainage for culture and sensitivity is crucial for identifying the specific strain of MRSA and determining the most effective antibiotic treatment.
E. Standard precautions are always necessary, but a mask is not required unless there is a risk of splashing or the patient has a respiratory infection.
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