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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

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Reviewing the prognosis for the spouse does not address the immediate concern about the influenza vaccination’s impact on the spouse’s health.
B. Explaining that the influenza vaccination will actually help reduce the risk of transmission of influenza to the spouse undergoing chemotherapy addresses the client’s concern and provides accurate information.
C. Planning the vaccination for a day when the spouse is not receiving chemotherapy does not resolve the underlying issue of the vaccination’s effectiveness and safety.
D. Determining when the spouse will finish chemotherapy is not relevant to the immediate concern of the vaccination and its effects on the spouse’s health.

A. Administer a dose of acetaminophen PRN per prescription. B. Monitor the child's oxygen saturation level via pulse oximeter. C. Encourage the child to drink adequate amounts of cool, clear liquids. D. Instruct the mother to play with the child for stimulation and distraction.

Correct Answer is B

Explanation

A. Administering acetaminophen can help reduce fever and discomfort but does not directly address the respiratory distress indicated by tachypnea and stridor.
B. Monitoring the child's oxygen saturation level via pulse oximeter is essential to assess the severity of the respiratory distress. It provides critical information on the child's oxygenation status and helps guide further interventions.
C. Encouraging the child to drink adequate amounts of cool, clear liquids is beneficial for hydration but does not directly address the acute respiratory symptoms of irritability, tachypnea, and stridor.
D. Instructing the mother to play with the child for stimulation and distraction may help alleviate irritability but does not address the underlying respiratory distress, which requires immediate attention.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

In assessing a 2-year-old boy with croup, the practical nurse (PN) finds that he has become increasingly irritable and has developed tachypnea and resting stridor. Which intervention is best for the PN to implement?

Correct Answer is B

Explanation

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the practical nurse (PN) should take to address that condition, and two parameters the PN should monitor to assess the client's progress.

An older adult client returns to the clinic for a follow-up visit with the healthcare provider for management of depression related to the death of a child, who was killed 6 months ago by a drunk driver. Which finding indicates to the practical nurse (PN) that the client is improving?

A client who is experiencing paralysis of the left arm curses at the practical nurse (PN) and throws a hairbrush against the wall using the right arm. How should the PN respond?

In performing a focused assessment, the practical nurse (PN) lifts the client's skin as seen in the photo. Which should the PN do next?

A client is receiving an epidural anesthesia during labor. Which observation is the most important adverse effect that the practical nurse (PN) should assess for following the administration of the epidural?

A client receives a prescription for digoxin 0.25 mg by mouth. The medication is available in 0.125 mg tablets. How many tablets should the practical nurse (PN) administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

In implementing the plan of care, which data should the practical nurse (PN) obtain first for a client with a sleep pattern disturbance?

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.