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
While the use of cocaine and heroin can pose various health risks, including cardiovascular complications, respiratory problems, and infectious diseases, Hepatitis is particularly associated with injection drug use, such as heroin. Hepatitis is an inflammation of the liver that can be caused by viral infections, including Hepatitis B and C. Sharing contaminated needles or other drug paraphernalia increases the risk of contracting Hepatitis. These viral infections can lead to chronic liver disease, liver cirrhosis, and even liver cancer if left untreated. Therefore, among the options provided, Hepatitis is the greatest health risk for this client due to the mode of drug administration and associated risks of viral transmission.
A, B, and C- It's important to note that while diabetes, glaucoma, and hypertension are all significant health conditions, they are not directly associated with the use of cocaine and heroin as drugs of choice. However, individuals who engage in substance abuse may still be at risk for developing or exacerbating other health conditions due to the overall impact on their physical and mental well-being.
Correct Answer is B
Explanation
In infants with heart failure, they may have difficulty feeding due to fatigue and increased work of breathing. Allowing the infant to rest before feeding helps conserve their energy and reduces the risk of excessive fatigue during feeding.
The other options are not appropriate interventions for this situation:
A.Weigh before and after feeding: Weighing before and after feeding is not necessary in this case unless specifically ordered by the healthcare provider. It is not directly related to the management of feeding an infant with heart failure.
C.Feed the infant when he cries: Feeding the infant solely based on crying may not be appropriate in this case. It is important to establish a feeding schedule and monitor the infant's signs of hunger and satiety to ensure adequate nutrition and prevent overfeeding.
D.Insert a nasogastric feeding tube: Inserting a nasogastric feeding tube should not be the first intervention unless there is a specific indication or order from the healthcare provider. In this scenario, the focus is on supporting oral feeding and allowing the infant to rest before feeding.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today