After the change-of-shift report, the practical nurse (PN) makes rounds on a postoperative unit. Which client finding necessitates the Immediate attention of the PN?

An older client whose blood pressure (BP) is 100/70 after receiving meperidine for pain related to a hip fracture.

A client who has pink urine draining from the indwelling urinary catheter following transurethral prostatectomy.

A client who is having bright red drainage from the rectum following a colonoscopy with polyp removal.

A client who has brown-green bile draining from a T-tube after cholecystectomy for cholelithiasis.

Answer and Explanation

The Correct Answer is C

The client finding that necessitates immediate attention by the practical nurse (PN) is a client who is having bright red drainage from the rectum following a colonoscopy with polyp removal. Bright red rectal bleeding can indicate active bleeding and immediate intervention is required to assess the severity of the bleeding, control the bleeding if possible, and prevent further complications.
A. The older client with a blood pressure of 100/70 after receiving meperidine for pain may require further assessment, but it does not indicate an immediate life-threatening condition.
B. Pink urine draining from the indwelling urinary catheter following a transurethral prostatectomy may be expected due to the surgical procedure, but it should still be monitored.
D. Brown-green bile draining from a T-tube after cholecystectomy for cholelithiasis is also an expected finding.

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Correct Answer is A

Explanation

This is the correct answer, as it reﬂects the nurse's assessment of the injury and the appropriate action to take. The nurse should consider the mother's report of pain as a valid indicator of the severity of the injury, and should not dismiss or minimize it. The nurse should also observe the boy's arm and shoulder for any signs of fracture, dislocation, swelling, bruising, or deformity, and ask him to rate his pain on a scale of 0 to 10. The nurse should then decide whether to refer the boy to a physician or an emergency department for further evaluation and treatment.

A. Dry mouth with thirst. B. Warm skin with elastic turgor. C. Low-grade fever with diaphoresis. D. Hives with pruritus.

Correct Answer is D

Explanation

Hives (also known as urticaria) are raised, red, itchy welts on the skin that can be caused by an allergic reaction to medication, including antibiotics. It is essential for the PN to recognize this potentially severe allergic reaction and take immediate action.

Immediate action steps include:

Stop the infusion of the intravenous antibiotic immediately.
Notify the healthcare provider and report the allergic reaction.
Assess the client's airway, breathing, and circulation to ensure there are no signs of respiratory distress or anaphylaxis.
Administer prescribed emergency medications if needed (e.g., epinephrine, antihistamines).
Monitor the client closely for any further signs of an allergic reaction or anaphylaxis.

The other assessment findings mentioned are also important to address, but they do not require immediate action:

A- Dry mouth with thirst: This may indicate dehydration, which should be addressed by encouraging the client to drink fluids, but it does not pose an immediate threat to the client's safety.

B- Warm skin with elastic turgor: This suggests that the client is adequately hydrated, and the skin's elasticity is normal, which is a positive finding.

C- Low-grade fever with diaphoresis: A low-grade fever indicates a mild elevation in temperature, and diaphoresis (sweating) may be the body's response to regulate temperature. The PN should monitor the client's temperature and assess for other signs of infection, but this finding does not require immediate action

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After the change-of-shift report, the practical nurse (PN) makes rounds on a postoperative unit. Which client finding necessitates the Immediate attention of the PN?

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Naxlex Comprehensive Predictor Exams

The mother of a school-aged boy tells the practical nurse (PN) that he fell out of a tree and hurt his arm and shoulder. The mother says the boy is in pain and needs medical help. The nurse should assess the injury and decide the appropriate action to take.

Correct Answer is A

Explanation

The practical nurse (PN) is providing care for a client who is receiving an intravenous antibiotic to treat an infection. Which assessment findings require the most immediate action by the PN?

Correct Answer is D

Explanation

The charge nurse brings a #18 urinary catheter with a 30 mL balloon to the practical nurse (PN) who is preparing to insert a catheter in a female client who weighs 50 kg. Which action should the PN take first?

A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the practical nurse (PN) implement first?

The practical nurse (PN) is auscultating a client's heart sounds. Which abnormal heart sound should the PN report to the charge nurse? (Please listen to the audio file to select the option that applies.)

Exhibits here Review H and P and nurse's notes. What other assessment techniques can the nurse use to identify the potential source of the client's new-onset confusion and decreased appetite? Select all that apply.

An older female client who resides in a long-term care facility has a male friend who often visits her in the evenings. The practical nurse (PN) enters the client's room to administer medications and finds the couple in bed together. What action should the PN take?

A 15-year-old adolescent male with a mild mental disability is hospitalized for minor surgery and tells the practical nurse (PN), "WOW! You have big breasts." Which response is best for the PN to provide?