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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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Correct Answer is ["A","D","E"]

Explanation

A. Oatmeal is a good choice for breakfast.
Oatmeal is a good source of iron and can be part of a vegetarian diet. It is a suitable option for increasing iron intake while adhering to vegetarian dietary restrictions.
B. Eat red meat just until the anemia is resolved.
This option is not suitable for a vegetarian client. Red meat is a source of heme iron, but it conflicts with the client’s dietary preferences and does not align with a vegetarian diet.
C. Take two prenatal vitamins with iron daily.
Doubling the dose of prenatal vitamins is not recommended without specific advice from a healthcare provider. The prescribed dosage should be followed, and dietary changes should be the focus.
D. Add lentils and black beans to soups.
Lentils and black beans are excellent sources of non-heme iron, which fits well within a vegetarian diet. Including these foods in meals can help boost iron levels effectively.
E. Increase green leafy vegetables in the diet.
Green leafy vegetables are high in non-heme iron and are suitable for vegetarians. Increasing their consumption supports iron intake and helps manage anemia.

A. Tell the client to see the good parts of life with two children who love the client. B. Provide the client with information about the Multiple Sclerosis Society. C. Allow the client to be alone by providing privacy to grieve. D. Sit quietly with the client and answer questions the client may ask.

Correct Answer is D

Explanation

A. Telling the client to focus on the positive aspects of life might seem dismissive of the client's current emotional state and concerns.
B. Providing information about support groups is helpful but should follow an initial supportive and empathetic response.
C. Allowing the client privacy may be necessary later, but initially, it is important to offer support and presence.
D. Sitting quietly with the client and answering any questions demonstrates empathy, support, and availability, helping the client process the new diagnosis and feel less isolated.

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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 ["A","D","E"]

Explanation

Correct Answer is D

Explanation

The practical nurse (PN) and unlicensed assistive personnel (UAP) are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere. Which action should the PN implement?

The practical nurse (PN) is assigning care for a group of clients on the urology medical unit. What client care interventions should the PN assign to the unlicensed assistive personnel (UAP)? Select all that apply.

A client is voiding frequent small amounts 24-hours following the removal of an indwelling catheter, and a post-voided residual volume assessment is prescribed. Which explanation should the practical nurse (PN) provide to the client about why the procedure is necessary?

Before administering zolpidem at bedtime, which client assessment should the practical nurse (PN) complete?

The practical nurse (PN) receives change of shift report on a postpartum unit. Which client should receive the PN's attention first?

The practical nurse (PN) assesses a child in 90-90 skeletal traction. It is most important for the PN to assess for signs of inflammation at which location?

Which location should the practical nurse (PN) palpate to determine if a client's submandibular lymph nodes are enlarged?

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.