While changing the dressing of a client's abdominal incision, the practical nurse (PN) observes a large amount of purulent drainage on the dressing. Which data should the PN collect first?
Measure the client's body temperature.
Observe the appearance of the incision.
Assess the degree of skin elasticity.
Determine the client's oxygen saturation.
The Correct Answer is A
A. Measure the client’s body temperature: Fever would indicate a systemic infection and helps assess the severity.
B. Observe the appearance of the incision: Important, but systemic assessment for infection should be prioritized first.
C. Assess the degree of skin elasticity: Checks hydration status but is unrelated to assessing wound infection severity.
D. Determine the client’s oxygen saturation: Not the priority unless respiratory distress is suspected.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The child will no longer be contagious, no need to take any further precautions:
RSV remains contagious for days to weeks after symptoms begin.
B. Make sure there are no children under the age of 6 months around the infected child:
Although infants are more vulnerable, all children are at risk - restriction should apply to everyone.
C. The child can be around other children but should wear a mask at all times:
Masks are not fully effective in preventing RSV spread, especially in very young children.
D. Do not expose other children as the virus is very contagious even without direct oral contact:
RSV spreads through respiratory droplets and contaminated surfaces.
Correct Answer is C
Explanation
A. Client with urinary urgency asking for a bedpan: UAP can assist with elimination needs.
B. Client with paraplegia needing condom catheter change: UAP can perform this with training.
C. Client with continuous bladder irrigation via 3-way catheter: Requires assessment of output, tubing patency, and potential complications - nursing responsibility.
D. Client with a full bedside drainage unit after diuretic: UAP can empty and measure output.
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