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 D
Explanation
Choice A: Increasing oral fluids may help with hydration, but it will not reduce skin flushing caused by lisinopril. Lisinopril is an angiotensin-converting enzyme (ACE. inhibitor that dilates blood vessels and lowers blood pressure. Flushing occurs due to increased blood flow to the skin.
Choice B: Nitroglycerin is a vasodilator that relaxes smooth muscle in blood vessels and reduces chest pain caused by angina. It is not indicated for skin flushing caused by lisinopril. Moreover, nitroglycerin can lower blood pressure further and cause hypotension, headache, dizziness, and fainting.
Choice C: Going to an emergency department is not necessary for skin flushing caused by lisinopril. Flushing is not a sign of an allergic reaction or anaphylaxis, which would require immediate medical attention. Flushing is also not a symptom of a heart attack or stroke, which would present with other signs such as chest pain, shortness of breath, arm numbness, or slurred speech.
Choice D: Reassuring the client that facial flushing is a common side effect of lisinopril is the best action for the nurse to take. Flushing is not harmful or dangerous, and it usually subsides within a few hours. The nurse should explain the mechanism of action of lisinopril and its benefits for lowering blood pressure and preventing angina. The nurse should also advise the client to monitor his blood pressure regularly and report any signs of hypotension, such as dizziness, lightheadedness, or fainting.
Correct Answer is C
Explanation
Choice A reason: Blood pressure, heart rate, and temperature are vital signs that should be monitored in any client, but they are not laboratory results. ESRD can cause hypertension and cardiovascular complications, so blood pressure and heart rate should be controlled with medications and lifestyle modifications. Temperature should be monitored for signs of infection or inflammation.
Choice B reason: Leukocytes, neutrophils, and thyroxine are not specific laboratory results for ESRD. Leukocytes and neutrophils are types of white blood cells that indicate immune system activity and infection. Thyroxine is a thyroid hormone that regulates metabolism and growth. ESRD can affect the immune system and the thyroid function, but these are not the primary indicators of renal function.
Choice D reason: Erythrocytes, hemoglobin, and hematocrit are laboratory results that measure red blood cell count, oxygen-carrying capacity, and blood volume. ESRD can cause anemia due to reduced production of erythropoietin, a hormone that stimulates red blood cell formation in the bone marrow. Anemia can cause fatigue, pallor, shortness of breath, and chest pain. However, these are not the most significant laboratory results for ESRD.
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