A nurse is caring for a client.
What are the first two actions the nurse should take?
Notify the healthcare provider and initiate treatment for TB.
Repeat the tests and compare the results with the previous ones.
Review the client's medical history and assess for symptoms.
Educate the client about TB prevention and management.
The Correct Answer is C
The first two actions the nurse should take are to review the client’s medical history and assess for symptoms.
This can help determine if further testing or treatment is necessary.
Choice A is wrong because the test results are negative, so initiating treatment for TB is not necessary.
Choice B is wrong because repeating the tests may not provide any additional information.
Choice D is wrong because educating the client about TB prevention and management may not be necessary if the client does not have TB.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C"]
Explanation
Leaving the drain until the end of the shift is not appropriate because it could lead to complications such as:
- Hematoma formation:Blood accumulation in the tissues surrounding the drain can put pressure on surrounding structures,potentially impairing blood flow and causing tissue damage.
- Infection:A reservoir containing blood provides a favorable environment for bacterial growth,increasing the risk of infection.
- Drain occlusion:Clotted blood can block the drain,preventing effective drainage and leading to fluid buildup and potential infection.
- Decreased wound healing:Excessive blood loss can delay wound healing by depriving the tissues of necessary oxygen and nutrients.
Removing the drain without the surgeon's order is not appropriate because:
- Premature removal:It could disrupt the healing process and lead to complications such as fluid collection or infection.
- Assessment limitation:Removing the drain would eliminate the ability to monitor ongoing blood loss and could mask potential complications.
A Jackson-Pratt drain works by creating suction when the bulb is squeezed and emptied¹. The bulb should be emptied before it is more than half full to avoid the discomfort of the weight of the drain pulling on the internal tubing and to maintain the suction
Notifying the surgeon about the blood loss is wrong because it is not an urgent situation unless there are signs of excessive bleeding, such as bright red blood, clots, or a sudden increase in the amount of drainage²³. The surgeon should be notified if the drainage is more than 100 ml in 24 hours or if the color changes from serosanguineous (pink) to sanguineous (red)
Correct Answer is A
Explanation
This statement indicates that the nurse should properly position the fracture bedpan to facilitate its use.
The shallow end of the fracture bedpan should be placed under the client’s buttocks to provide support and comfort.
Choice B is wrong because hyperextending the client’s back can cause discomfort and may not facilitate the use of the fracture bedpan.
Choice C is wrong because it is not necessary for the client to try to defecate for 20 minutes while on the fracture bedpan.
Choice D is wrong because keeping the bed flat may not provide the most comfortable position for the client while using the fracture bedpan.
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