Exhibits
The practical nurse (PN) performs a focused assessment and documents it in the computer. Select what items require immediate follow-up by the PN. Select all that apply.
Respiratory rate 18 breaths/minute
Heart rate 101 beats/minute
Capillary refill 2 seconds
Breath sounds clear and equal bilaterally
Turban dressing is saturated with serosanguinous drainage
Blood pressure 140/84 mm Hg
Temperature 101.9° F (38.8° C)
Client is awake and alert
Correct Answer : B,E,G
A. Respiratory rate 18 breaths/minute
The respiratory rate is within the normal range for an adult (12-20 breaths/minute). No immediate follow-up is required for this vital sign.
B. Heart rate 101 beats/minute
An elevated heart rate (tachycardia) can indicate several issues, including fever, infection, or pain. In the context of a surgical site infection and elevated temperature, tachycardia is a sign of systemic response and needs to be evaluated further to determine the cause and appropriate intervention.
C. Capillary refill 2 seconds
Capillary refill time of 2 seconds is within the normal range (≤ 2 seconds) and indicates adequate perfusion. No immediate follow-up is needed.
D. Breath sounds clear and equal bilaterally
This finding indicates no acute respiratory issues. No immediate follow-up is necessary based on this assessment.
E. Turban dressing is saturated with serosanguinous drainage
Saturation of the dressing with serosanguinous drainage indicates a significant amount of wound drainage, which could suggest worsening of the infection or a new complication. This finding requires immediate follow-up to assess the wound and determine if additional interventions or changes in treatment are necessary.
F. Blood pressure 140/84 mm Hg
While slightly elevated, this blood pressure reading is not excessively abnormal and does not require immediate follow-up in the absence of other symptoms. Monitoring is required but not urgent.
G. Temperature 101.9° F (38.8° C)
An elevated temperature indicates a fever, which is a sign of infection. Given the positive MRSA culture and the need for infection control, this temperature warrants immediate follow-up to assess for worsening infection and determine the need for antipyretics or antibiotics.
H. Client is awake and alert
Being awake and alert is a positive finding and does not require immediate follow-up
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Bringing the client to sit at the nursing station may not address the underlying cause of the wandering behavior and could be less effective in meeting the client’s immediate needs.
B. Administering a nighttime sedative is not a suitable solution for wandering behavior, as it may lead to adverse effects and does not address the root cause of the behavior.
C. Directing the client to go back to bed may not be effective, especially if the client is disoriented or confused. The approach should involve understanding and addressing the client's needs.
D. Engaging the client to determine current needs is the best approach, as it helps to understand the cause of the wandering and address it appropriately, such as providing comfort, reassurance, or addressing a specific need.
Correct Answer is C
Explanation
A. Extending progressive ambulation over one week is important but not the most critical instruction. Postoperative mobility is generally encouraged in a gradual manner, but it is not as urgent as managing specific activity restrictions.
B. Notifying the clinic if the child begins bedwetting is not typically a primary concern immediately following surgery for cryptorchidism. Bedwetting is not directly related to the surgical procedure or its common postoperative concerns.
C. Restricting the child from playing on riding toys is the most important instruction for preventing complications. Riding toys can be a safety risk due to potential trauma to the surgical site and could cause harm during the recovery period.
D. Supervising toileting to prevent picking at sutures is relevant but less critical compared to the need to restrict potentially harmful activities. While important, it is a secondary concern compared to overall activity restrictions.
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