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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

When a client's family member expresses concerns about the care provided, it is essential for the nurse to gather more information and understand the specific issues raised. By asking for a description of what happened during the night, the nurse can obtain details about the perceived inadequate care. This allows the nurse to gather accurate information, assess the situation, and address any legitimate concerns.
A. Explaining that all staff are doing their best may not address the specific issues raised by the daughter and may not provide a satisfactory resolution to her concerns.
B. Telling the daughter to talk with the unit's nurse manager can be an appropriate step, but it should come after gathering information about the situation. The nurse needs to have a clear understanding of what happened before involving the nurse manager.
C. Reassuring the daughter that the mother will get better care may not address her concerns and may not provide a solution to the perceived problem. It is important to gather more information before offering reassurance or making promises.

A. Consult with the charge nurse about implementing suicide precautions. B. Sit quietly in the client's room until the client is ready to verbalize his feelings. C. Notify a member of the client's family of the need to come stay with the client. D. Leave the room after oﬀering to return to the client's room at a later time. E. Leave the room after oﬀering to return to the client's room at a later time.

Correct Answer is D

Explanation

This is the action that the PN should implement for a male client who has just been told he has cancer and asks to be left alone. Leaving the room after oﬀering to return later respects the client's autonomy and privacy, while also showing empathy and availability. The client may need some time and space to process the diagnosis and cope with his emotions. The PN should not force the client to talk or stay with him if he does not want to, but should also not abandon him or ignore his needs.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client's daughter phones the charge nurse to report that the night nurse did not provide good care for her mother. Which response should the practical nurse (PN) make?

Correct Answer is D

Explanation

A male client who has just been told he has cancer asks the practical nurse (PN) to leave his room so he can be alone. Which action should the PN implement?

Correct Answer is D

Explanation

Before administering an antibiotic that can cause nephrotoxicity, which laboratory value is most important for the practical nurse (PN) to review?

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