When monitoring a client's abdominal incision, the practical nurse (PN) observes a large amount of sanguineous drainage on the dressing. Which client data collection should the PN complete first?
Temperature.
Pain scale.
Bowel sounds.
Blood pressure.
The Correct Answer is A
The correct answer is Choice A. Temperature. Choice A rationale:
The practical nurse (PN) should complete the data collection for temperature first. A large amount of sanguineous drainage on the abdominal incision dressing could indicate possible infection or a change in the client's condition. Elevated temperature may be an early sign of infection, which requires immediate attention and appropriate intervention.
Choice B rationale:
Assessing the pain scale is important, but it can be addressed after completing the data collection for temperature. Pain assessment is essential for providing appropriate pain management, but it is not the most urgent concern when there is a significant amount of drainage from the incision site.
Choice C rationale:
Checking bowel sounds is relevant in postoperative care, but it is not the priority at this moment. Abdominal incision drainage takes precedence as it may indicate a more critical issue that requires immediate attention.
Choice D rationale:
Monitoring blood pressure is essential, but it is not the most immediate concern in this scenario. A large amount of sanguineous drainage from the abdominal incision takes precedence over blood pressure monitoring at this time.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is the best intervention for the PN to implement because it monitors the client's fluid status and helps detect fluid overload, which can cause hypertension and neurological changes. The PN should weigh the client at the same time, on the same scale, and with the same clothing every day.
A. Using a cushion when sitting is not a priority intervention for this client and may not address the BP or mental status issues.
B. Performing range of motion exercises is not a priority intervention for this client and may not address the BP or mental status issues.
C. Documenting abdominal girth is not a priority intervention for this client and may not be an accurate indicator of fluid status.
Correct Answer is C
Explanation
The correct answer is Choice C:
Suggest that an increase in fruits and vegetables is more beneficial.
Choice C rationale:
While dairy products do provide essential nutrients like calcium and vitamin D, there is no strong evidence to suggest that increasing dairy intake alone will significantly reduce the risk of cancer. On the other hand, fruits and vegetables are known to be rich in antioxidants and phytochemicals that have been associated with a reduced risk of cancer. Therefore, suggesting an increase in fruits and vegetables is a more evidence-based approach to reducing cancer risk.
Choice A rationale:
Encouraging exercise is a good recommendation for overall health, but it does not directly address the client's concern about reducing cancer risk. Focusing on a balanced diet, including plenty of fruits and vegetables, is more relevant to the client's specific concern.
Choice B rationale:
Reminding the client about Vitamin D-fortified dairy products may be helpful for addressing Vitamin D intake, but it doesn't necessarily address the broader concern of reducing cancer risk. Moreover, the link between dairy and cancer risk reduction is not as well-established as the benefits of fruits and vegetables.
Choice D rationale:
Providing information about cancer warning signs is important for cancer awareness but doesn't address the client's current dietary choices and concerns about cancer prevention. The focus should be on evidence-based dietary recommendations to reduce cancer risk.
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