A registered nurse is providing ongoing post-operative care to a client who has had knee surgery. The nurse assesses the surgical dressing and finds it saturated with blood. The client is restless and has a rapid pulse.
What should the nurse do next?
Make assessments every 15 minutes for four hours.
Document the data, remove the old dressing and apply a new dressing.
Apply a well-secured additional pressure dressing and report findings.
Reassure the family that this is a common problem.
The Correct Answer is C
Rationale for Choice A:
Making assessments every 15 minutes for four hours does not directly address the immediate concern of blood loss and potential hemodynamic instability. While close monitoring is essential, it's not the primary action in this situation.
Excessive blood loss can rapidly lead to hypovolemic shock, which requires prompt intervention to prevent serious complications.
Relying solely on frequent assessments without active interventions could delay crucial treatment and compromise patient safety.
Rationale for Choice B:
Documenting the data, removing the old dressing, and applying a new dressing might be necessary at some point, but it's not the most urgent priority in this case.
Removing the dressing could disrupt clot formation and potentially worsen bleeding.
Applying a new dressing without addressing the underlying bleeding might not effectively control the blood loss. Rationale for Choice C:
Applying a well-secured additional pressure dressing is the most appropriate immediate action to help control bleeding and prevent further blood loss.
It provides direct compression to the surgical site, promoting hemostasis and reducing blood flow. This action prioritizes stabilizing the patient's condition and preventing further complications.
Reporting the findings to the healthcare provider is crucial for timely assessment, diagnosis, and management of potential complications, such as hemorrhage or hematoma.
It ensures collaboration with the healthcare team and facilitates appropriate interventions based on the patient's specific needs.
Rationale for Choice D:
Reassuring the family that this is a common problem might provide some comfort, but it doesn't address the patient's immediate needs or the potential severity of the situation.
It's essential to prioritize patient safety and provide interventions to control bleeding, even if bleeding is a known potential complication.
Transparency and clear communication with the family are important, but they should not replace necessary medical interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Total urinary incontinence is the involuntary loss of all urine from the bladder. It is not synonymous with micturition, which is a controlled process of bladder emptying.
Incontinence can stem from various factors, including neurological disorders, muscle weakness, medication side effects, and structural abnormalities.
It's essential to distinguish between incontinence and micturition for accurate diagnosis and treatment.
Choice B rationale:
Micturition, also known as urination or voiding, is the physiological process of emptying the urinary bladder. It involves a coordinated interplay between the nervous system, bladder muscles, and urethral sphincters. When the bladder fills with urine, stretch receptors signal the nervous system, prompting the urge to urinate. If conditions are appropriate, the nervous system initiates a series of events:
The detrusor muscle in the bladder wall contracts.
The internal urethral sphincter relaxes, opening the pathway for urine to flow.
The external urethral sphincter, under voluntary control, relaxes to allow urine to pass through the urethra and out of the body.
Choice C rationale:
The inability to completely empty the bladder is called urinary retention.
It can result from various causes, including obstruction (e.g., enlarged prostate, urethral stricture), neurological disorders, medications, and pelvic floor dysfunction.
Urinary retention differs from micturition, as it involves incomplete bladder emptying.
Choice D rationale:
Catheterization is the process of inserting a thin, flexible tube (catheter) into the bladder to drain urine.
It's a medical procedure performed for various reasons, such as urinary retention, bladder obstruction, or to collect urine samples.
Catheterization is not a natural process of micturition, but a medical intervention.
Correct Answer is ["65"]
Explanation
Here are the steps to calculate the flow rate in gtt/min:
Step 1: Calculate the total volume of fluid to be infused.
The order is for 1.5 grams of Ampicillin added to 100 mL of Normal Saline, so the total volume is 100 mL. Step 2: Calculate the number of vials of Ampicillin needed.
Each vial contains 500 mg of Ampicillin, and the order is for 1.5 grams (which is 1500 mg). Therefore, you will need 3 vials of Ampicillin (1500 mg ÷ 500 mg/vial = 3 vials). Step 3: Calculate the total volume of Ampicillin solution.
Each vial contains 10 mL of Ampicillin solution, and you need 3 vials.
Therefore, the total volume of Ampicillin solution is 30 mL (3 vials × 10 mL/vial = 30 mL). Step 4: Calculate the total volume to be infused, including the Ampicillin solution. The total volume is 100 mL of Normal Saline + 30 mL of Ampicillin solution = 130 mL. Step 5: Calculate the infusion time in minutes.
The order is to infuse over 120 minutes.
Step 6: Calculate the flow rate in gtt/min.
Use the formula: Flow rate (gtt/min) = Total volume (mL) × Drop factor (gtt/mL) ÷ Infusion time (min) Plug in the values: Flow rate = 130 mL × 60 gtt/mL ÷ 120 min
Simplify: Flow rate = 7800 ÷ 120
Flow rate = 65 gtt/min
Therefore, the flow rate in gtt/min in which the IV fluid is to flow is 65 gtt/min.
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