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
This is the correct answer because BUN and creatinine are the most important laboratory values to monitor for nephrotoxicity, which is the damage or injury to the kidneys caused by certain drugs or chemicals.
Nephrotoxicity can impair the kidneys' ability to filter waste products from the blood, resulting in elevated levels of BUN and creatinine. The normal range for BUN is 7 to 20 mg/dL, and for creatinine is 0.6 to 1.2 mg/dL. The practical nurse (PN) should review these values before administering an antibiotic that can cause nephrotoxicity, such as aminoglycosides, cephalosporins, vancomycin, or sulfonamides. The PN should also monitor the client for signs and symptoms of nephrotoxicity, such as decreased urine output, edema, hypertension, fatigue, nausea, and confusion.
Correct Answer is A
Explanation
Inspecting the client's skin near the end of the bathing procedure allows the PN to directly assess the UAP's performance and evaluate the effectiveness of the bed bath. By observing the client's skin, the PN can determine if the UAP has properly cleaned and cared for the client's skin, identified any areas that may have been missed, and ensured that proper hygiene practices have been followed.
B. While verifying with the client that the bath was complete and thorough is important for client satisfaction, it may not provide a comprehensive evaluation of the UAP's performance. Clients may not be aware of all the necessary steps involved in a complete bed bath, so their perception may not accurately reflect the quality of the UAP's work.
C. Requesting the UAP to report and chart when the bath is complete is a useful documentation practice, but it does not provide a direct evaluation of the UAP's performance during the bed bath.
D. Asking another UAP to help the orientee may be helpful for providing guidance and support during the orientation process, but it does not provide a specific evaluation of the UAP's performance in completing the bed bath.
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