The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first?

An adult who is in Buck's traction, and scheduled for hip arthroplasty within the next 12 hours.

An older client who is receiving packed red blood cells on the third day postoperatively for colon resection.

An older client with continuous bladder irrigation who is 2 days postoperatively for bladder surgery.

An adult one day postoperative laparoscopic cholecystectomy requesting pain medication.

Answer and Explanation

The Correct Answer is B

A)   Incorrect- Hip arthroplasty is a scheduled procedure, and there is no immediate indication of a critical condition that requires urgent attention.
B)   Correct- Postoperative hemorrhage is a serious complication, and an older client receiving packed red blood cells may be experiencing active bleeding. This situation requires immediate assessment and intervention.
C)   Incorrect- While continuous bladder irrigation requires monitoring, it is not as urgent as a potential postoperative hemorrhage.
D)   Incorrect- Pain management is important, but it is not as urgent as assessing a client who may be experiencing active bleeding.

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Correct Answer is C

Explanation

A) Incorrect- This position is not ideal for managing a nosebleed because it does not promote drainage and may lead to blood flowing down the throat.
B) Incorrect- Leaning the head backward can cause blood to flow down the throat and may lead to choking or aspiration.
C) Correct- Placing the child in a sitting position and leaning forward helps prevent blood from flowing down the back of the throat, which can lead to choking or aspiration. Leaning forward allows the blood to drain out through the nostrils.
D) Incorrect- Placing the child in a supine position with raised legs is not recommended for managing a nosebleed, as it may lead to blood flowing down the throat.

A. Level of consciousness B. Capillary refill C. Temperature D. Blood pressure F. Pupil size and reactiveness G. Skin turgor H. Heart rate

Correct Answer is ["B","C","D","E","H"]

Explanation

Capillary refill: This is a quick and simple way to assess the adequacy of peripheral perfusion and can help identify signs of dehydration.
Skin turgor: Assessing the skin turgor, or the elasticity of the skin, is another useful indicator of dehydration.
Heart rate: Tachycardia can be a sign of dehydration, so monitoring the heart rate is an important component of the assessment.
Blood pressure: Blood pressure can be affected by dehydration, so monitoring it is important in determining the severity of dehydration and in guiding appropriate interventions.
Temperature: Fever is a potential cause of dehydration, so monitoring the temperature is an important part of the assessment.
Skin color of hands and feet: Checking the color of the skin on the hands and feet can help identify signs of poor perfusion and dehydration.

Assessing the level of consciousness, pupil size and reactiveness, and respiratory rate are important aspects of the neurological and respiratory assessments but are not specific to the assessment of dehydration.

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The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first?

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Naxlex Comprehensive Predictor Exams

The school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In which position should the nurse place the child?

Correct Answer is C

Explanation

Patient Data History and Physical Nurses' Notes Laboratory Results Flow Sheet Exhibits here Review H and P, nurse's note, laboratory result, and flow sheet. What information should the nurse collect as part of the focused assessment for dehydration in this child? Select all that apply.

Correct Answer is ["B","C","D","E","H"]

Explanation

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