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
Gently blowing the nose helps to clear any mucus or debris from the nasal passages, allowing for better delivery and absorption of the medication. It also helps to ensure that the nasal passages are clear and open, allowing the medication to reach its intended target.
A. Deep breathing and coughing are unrelated to the administration of nasal spray and are not necessary before using the medication.
B. Checking glucose levels before and after administration is not relevant for fluticasone furoate nasal spray. Glucocorticoid nasal sprays are not typically associated with significant effects on blood glucose levels.
C. Exhaling through the mouth is not a specific action required before using the nasal spray. It may be a general instruction for some other respiratory therapies or procedures, but it is not directly related to the administration of the nasal spray.
Correct Answer is ["A","B","C","E","F","G"]
Explanation
Based on the given information, the statements that indicate the client's confusion is resolving are:
- Asks how long he has been in the hospital: This shows cognitive awareness and the ability to ask relevant and coherent questions.
- States he is hungry: This indicates a return to normal appetite and the ability to recognize and express basic needs.
- Recognizes his daughter: This demonstrates the ability to recognize and identify a familiar individual, suggesting an improved level of cognitive functioning.
- Oriented to time, place, and self: Being aware of the current time, location, and personal identity reflects an improved level of orientation and mental clarity.
The following statements suggest ongoing confusion or potential issues:
- Clawing at the air: This behavior may indicate restlessness, agitation, or disorientation.
- Keeps trying to get out of bed to find the swimming pool: This behavior may indicate confusion or an altered perception of reality.
The statement "Drinking broth" does not directly indicate the resolution of confusion but may reflect the client's willingness and ability to consume food.
The statement "Oxygen saturation on 0.5L of 100%" provides information about the client's oxygen saturation level but does not specifically address the resolution of confusion.
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