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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

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. Moisture is important for skin assessments but does not directly affect the accuracy of a temporal artery temperature measurement.
B. Elasticity is part of skin turgor assessments and does not impact the accuracy of the temperature reading from a temporal artery scanner.
C. Assessing skin color is crucial because variations in skin color can affect the accuracy of the temporal artery temperature measurement. For accurate results, the skin should be clean and free of color alterations.
D. Checking the temperature of the skin is the outcome of the measurement process rather than a preliminary assessment for a temporal artery scanner.

A. Explore the client's thoughts about dying. B. Propose to notify the family of the request. C. Suggest that the hospital chaplain is available. D. Offer to contact the priest for the client.

Correct Answer is D

Explanation

A. Exploring the client’s thoughts about dying is supportive but not the immediate priority when a specific request for a religious ritual is made.
B. Notifying the family of the request is a secondary action but should follow the immediate fulfillment of the client's request for spiritual support.
C. Suggesting that the hospital chaplain is available might be appropriate, but the client's specific request was for a priest, and it is better to offer to contact the priest directly.
D. Offering to contact the priest for the client directly addresses the client's immediate spiritual need and respects their request.

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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

The practical nurse (PN) positions a temporal artery scanner as seen in the picture. Before obtaining a temperature measurement, which assessment of the skin should the PN complete?

Correct Answer is C

Explanation

The practical nurse (PN) is caring for a hospice client who requests a priest for the "Last Rites." Which should be the next response by the PN?

Correct Answer is D

Explanation

The practical nurse (PN) is assessing an older adult client with left-sided heart failure (HF). Which intervention is most important for the PN to implement?

While caring for a client one day following a thyroidectomy, the practical nurse (PN) notes that the client's voice is hoarse. Which action should the PN take?

A newborn's assessment reveals spina bifida occulta. Which maternal factor should the practical nurse (PN) identify as having the greatest impact on the development of this newborn complication?

The unlicensed assistive personnel (UAP) reports to the practical nurse (PN) that an older adult client has a radial pulse of 55 beats/minute. Which intervention should the PN implement first?

Exhibits The practical nurse (PN) is preparing to change the turban dressing. For each intervention, click to indicate whether it is indicated or not indicated for the dressing change. Each row must have one

The practical nurse (PN) is assigning tasks to an unlicensed assistive personnel (UAP) who is giving basic care to a group of residents in a long-term care facility. Which client's task should be completed by a PN, rather than the UAP?

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.