After receiving report, the nurse can most safely plan to assess which client last?
An adult client with a tracheal tube draining clear, pale red liquid drainage
An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac.
An adult client with no postoperative drainage in the Jackson-Pratt drain with the bulb compressed.
An older client with a distended abdomen and no drainage from the nasogastric tube.
The Correct Answer is C
Choice A: An adult client with a tracheal tube draining clear, pale red liquid drainage. This client should not be assessed last, as they may have a potential airway obstruction or infection. The tracheal tube drainage should be monitored for color, amount, and consistency, and suctioned as needed.
Choice B: An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac. This client should not be assessed last, as they may have a potential hemorrhage or wound dehiscence. The postoperative dressing and Hemovac should be monitored for color, amount, and odor, and changed as needed.
Choice C: An adult client with no postoperative drainage in the Jackson-Pratt drain with the bulb compressed. This client can be assessed last, as they have no signs of complications or problems. The Jackson-Pratt drain is a closed suction device that collects fluid from a surgical site. The bulb should be compressed to create negative pressure and facilitate drainage.
Choice D: An older client with a distended abdomen and no drainage from the nasogastric tube. This client should not be assessed last, as they may have a potential bowel obstruction or perforation. The nasogastric tube is inserted through the nose into the stomach to decompress gas and fluid. The abdomen should be monitored for size, shape, and bowel sounds, and the nasogastric tube should be checked for patency and placement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: This hernia is a normal variation that resolves without treatment is a correct explanation for the nurse to provide, as this refers to an umbilical hernia, which is a common and harmless condition in infants that usually disappears by age 2. Therefore, this is the correct choice.
Choice B: An abdominal binder can be worn daily to reduce the protrusion is not an appropriate explanation for the nurse to provide, as this is not an effective or recommended method to treat a hernia. This is a distractor choice.
Choice C: Restrictive clothing will be adequate to help the hernia go away is not a relevant explanation for the nurse to provide, as this does not affect the hernia or its resolution. This is another distractor choice.
Choice D: The quarter should be secured with an elastic bandage wrap is not a sensible explanation for the nurse to provide, as this is a folk remedy that has no scientific basis and can cause skin irritation and infection. This is another distractor choice.
Correct Answer is B
Explanation
Choice A: An abdominal binder can be worn daily to reduce the protrusion is not a correct explanation for the nurse to provide, as this is not an effective or recommended method to treat a hernia. This is a distractor choice.
Choice B: This hernia is a normal variation that resolves without treatment is a correct explanation for the nurse to provide, as this refers to an umbilical hernia, which is a common and harmless condition in infants that usually disappears by age 2. Therefore, this is the correct choice.
Choice C: The quarter should be secured with an elastic bandage wrap is not a correct explanation for the nurse to provide, as this is a folk remedy that has no scientific basis and can cause skin irritation and infection. This is another distractor choice.
Choice D: Restrictive clothing will be adequate to help the hernia go away is not a correct explanation for the nurse to provide, as this is not a proven or safe way to treat a hernia. This is another distractor choice.
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