Try Naxlex NCLEX-RN (Free-Trial)

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

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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

Explanation

A. Use a client-specific stethoscope.
Indicated: Using a client-specific stethoscope helps prevent the spread of MRSA between patients. Each client should have dedicated equipment to reduce cross-contamination.
B. Wipe the medication cart with bleach after bringing it into the room.
Not Indicated: While disinfection of surfaces is important, the cart should be cleaned according to hospital protocol, which may involve different cleaning agents. Bleach is not typically used for medication carts and might not be the standard protocol.
C. Measure the client's temperature with a disposable thermometer.
Indicated: Using a disposable thermometer or single-use covers for thermometers prevents the transmission of MRSA to other patients. This practice helps maintain infection control.
D. Change gloves between different clients.
Indicated: Gloves should be changed between patients to prevent the spread of MRSA. This is a standard infection control practice to avoid cross-contamination.
E. Pad the client's side rails with clean linens.
Not Indicated: While padding the side rails may be done for client comfort or safety, it does not specifically address the control of MRSA spread and is not a direct infection control measure for MRSA.

A. Your healthcare provider has left specific instructions to ambulate on the first postoperative day. B. I know you feel angry about the pain of ambulation, but this is a necessary part of getting well. C. I will be back in 30 minutes to help you get out of bed and walk around the room today. D. You must ambulate to avoid complications which could cause more discomfort than ambulating.

Correct Answer is C

Explanation

A. Stating that the healthcare provider left specific instructions may come across as confrontational and does not address the client's emotional state. The focus should be on empathetic communication rather than emphasizing authority.
B. While acknowledging the client’s feelings is important, this response may not de-escalate the situation. It focuses on the necessity of ambulation rather than addressing the client's anger and offering support.
C. Offering to return in 30 minutes provides the client with a sense of control and acknowledges their feelings. It is a supportive and respectful approach that allows time for the client to calm down and prepares them for ambulation.
D. Explaining that ambulation is necessary to avoid complications can sound directive and may not help in managing the client's anger. It is more effective to acknowledge the client's feelings and offer to help at a later time.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Exhibits Which 3 other interventions can the practical nurse (PN) initiate to limit the spread of methicillin-resistant Staphylococcus aureus (MRSA)?

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

Explanation

When the practical nurse (PN) attempts to assist an 18-year-old client with a mild mental disability to ambulate on the first postoperative day after an appendectomy, she becomes angry and yells at the PN, "Get out of here! I'll get up when I'm ready!" Which response is best for the PN to make?

Correct Answer is C

Explanation

The practical nurse (PN) is observing a newly hired unlicensed assistive personnel (UAP) bathing a client who has type 2 diabetes mellitus (DM). The UAP places the client's feet in a wash basin filled with warm soapy water to soak. Which action should the PN take?

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?

Exhibits The practical nurse (PN) notifies the healthcare provider that the client continues to have signs of fluid volume deficit. The health care provider prescribes a continuous infusion of isotonic fluids. Which fluid(s) is/are classified as isotonic? Select all that apply.

The practical nurse (PN) is assisting with data collection for clients who have been admitted to the emergency department. What clients should the PN report to the nurse for further intervention for possible family violence? Select all that apply.

The practical nurse (PN) views the mid-line episiotomy of a client who reports pain in her stitches. Which action should the PN take first?

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

At 1200, the practical nurse (PN) learns that a client's 0900 dose of an anticonvulsant was not given. The next scheduled dose is at 2100. Which action should the PN take?

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.