A male client who has just been told he has cancer asks the practical nurse (PN) to leave his room so he can be alone. Which action should the PN implement?

Consult with the charge nurse about implementing suicide precautions.

Sit quietly in the client's room until the client is ready to verbalize his feelings.

Leave the room after offering to return to the client's room at a later time.

Notify a member of the client's family of the need to come to stay with the client.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C: Leave the room after offering to return to the client's room at a later time.

Choice A rationale:

Consulting with the charge nurse about implementing suicide precautions is not appropriate in this situation. The client has not expressed suicidal ideation or intent, and such an action could be invasive and distressing for the client.

Choice B rationale:

Sitting quietly in the client's room until the client is ready to verbalize his feelings might seem supportive, but it disregards the client's request for alone time. It's essential to respect the client's wishes and provide an opportunity for self-reflection and privacy.

Choice C rationale:

Leaving the room after offering to return to the client's room at a later time is the most appropriate action. The client has requested solitude, and respecting his autonomy is crucial in building trust and rapport.

Choice D rationale:

Notifying a member of the client's family of the need to come stay with the client is not necessary at this point. The client's desire for alone time does not indicate an immediate need for family support. The practical nurse should first respect the client's request and give him space to process the news. If the client later expresses a need for family support, appropriate actions can be taken accordingly.

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Correct Answer is A

Explanation

This is the most important follow-up assessment for the PN to implement because it can detect signs of bleeding, infection, or shock that may result from the unsecured surgical dressing. The PN should monitor the client's blood pressure, pulse, temperature, and respiratory rate and report any abnormal changes.

B. Fluid volume intake and output is not the most important follow-up assessment for this client and may not reﬂect the current status of the client's ﬂuid balance or blood loss.

C. Volume of peripheral pulses is not the most important follow-up assessment for this client and may not be aﬀected by the unsecured surgical dressing unless it is located on a limb or near a major artery.

D. Incisional pain scale rating is not the most important follow-up assessment for this client and may not indicate the severity or cause of the client's pain.

A. C-reactive protein level B. Culture for sensitive organisms. C. Serum albumin. D. Serum blood glucose (BG) level.

Correct Answer is B

Explanation

The correct answer is choice B: Culture for sensitive organisms.

Choice A rationale:
C-reactive protein level - C-reactive protein (CRP) is a blood test marker for inflammation in the body. While it could indicate an infection, it is not specific enough to identify the type of infection or the causative organism.
Choice B rationale:
Culture for sensitive organisms - When a wound has a moderate amount of yellow and green drainage and a foul odor, it is often a sign of a bacterial infection. A culture for sensitive organisms can help identify the specific bacteria causing the infection, which is crucial for determining the most effective treatment.
Choice C rationale:
Serum albumin - Serum albumin levels can indicate a person’s nutritional status. Low levels can slow wound healing, but they do not directly indicate the presence of an infection.
Choice D rationale:
Serum blood glucose (BG) level - High blood glucose levels can impair the immune response and slow wound healing, making a person more susceptible to infections. However, like CRP, it does not provide information about the specific organism causing the infection.

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A male client who has just been told he has cancer asks the practical nurse (PN) to leave his room so he can be alone. Which action should the PN implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) finds a postoperative client lying in bed with an unsecured surgical dressing as seen in the picture. After reinforcing the dressing, which follow-up assessment is most important for the PN to implement?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

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