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 C
Explanation
When a client reports experiencing numbness and tingling in the extremities, it is crucial for the practical nurse (PN) to prioritize reporting the client's electrolyte levels to the healthcare provider. Electrolytes are essential minerals that help maintain the balance of fluids in the body and enable proper nerve and muscle function. Imbalances in electrolyte levels can lead to neurological symptoms, including numbness and tingling.
Options a, b, and d are not the correct priorities to report in this situation:
Correct Answer is D
Explanation
When the PN witnesses a situation where a resident is shouting profanities and a staff member (UAP) responds inappropriately, the immediate priority is to ensure the safety and well-being of the resident. It is essential to address the situation promptly and prevent further escalation.
Entering the room and instructing the UAP to leave immediately serves several purposes:
1. Protecting the resident: Removing the UAP from the room ensures that the resident is not subjected to further conflict or distress.
2. Maintaining a calm and therapeutic environment: By addressing the disruptive behavior and removing the staff member involved, the PN can help restore a peaceful environment for the resident and other individuals in the facility.
3. Ensuring professional conduct: Shouting and engaging in unprofessional behavior is not acceptable in a healthcare setting. By immediately intervening and directing the UAP to leave the room, the PN reinforces the importance of maintaining a respectful and professional approach to caregiving.
After addressing the immediate concern, the PN should follow up by reporting the incident and providing a detailed account to the nurse manager or supervisor. This allows for appropriate action to be taken, such as further investigation or disciplinary measures if necessary.
The other options mentioned are not the first actions to be taken in this situation:
A. Reporting the incident and the UAP for further action by the nurse manager: While reporting the incident is important, it is not the immediate action required to address the situation in
real-time.
B. Telling both of them to lower their voices in consideration of other residents: While promoting a calm environment is important, addressing the issue of shouting and unprofessional behavior takes precedence over requesting a volume reduction.
C. Telling the resident and the UAP that shouting is not permitted: While it is essential to communicate the expectations of behavior, the immediate focus should be on removing the staff member from the situation and ensuring the resident's well-being.
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