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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Has the child eaten recently? This is the correct and most important question to ask before administering insulin. The timing and content of the child's recent meals will directly impact their blood sugar levels and help determine the appropriate insulin dose. Insulin is typically administered in correlation with meals to maintain blood sugar within a target range and prevent hypo- or hyperglycemia.
A. Did the child perform a fingerstick? While checking the child's blood glucose level is an important part of diabetes management, it is not the most crucial piece of information to gather before administering insulin. The PN should prioritize knowing whether the child has eaten recently, as insulin administration should be coordinated with meals to prevent hypoglycemia or hyperglycemia.
B. How much did the child exercise today? Physical activity can affect blood sugar levels, but it is not the most critical information to obtain before administering insulin. The PN should focus on the child's food intake because insulin doses need to be adjusted accordingly to prevent fluctuations in blood sugar levels.
C. When did the child last urinate? While monitoring urinary patterns is important in assessing hydration and kidney function, it is not directly related to determining the appropriate insulin dose. The PN should prioritize gathering information about the child's recent food intake, as insulin administration needs to be coordinated with meals.
Correct Answer is D
Explanation
This is the best action to take for a client who experiences a sudden gush of vaginal blood and clots after a cesarean section. Massaging the fundus helps to stimulate uterine contractions and reduce bleeding. Avoiding direct pressure on the incision prevents pain and wound dehiscence.
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