The nurse receives a change-of-shift report from the prior nurse assigned to a group of clients on a post-surgical unit. Which client requires the most immediate intervention by the nurse?
A client who had an abdominal-perineal resection 3 days ago has no drainage on the dressing and is reporting chills.
A client who fell from a ladder and has a collapsed left lower lung with 100 mL drainage in a chest tube collection container.
A client who was admitted 4 hours ago with a gunshot wound and has a dressing with 2 cm-sized dark red drainage.
A client who is post-mastectomy 2 days ago and has 50 mL of serosanguineous fluid in a Jackson-Pratt drain.
The Correct Answer is A
Choice A reason: This client may have an infection or sepsis, which are life-threatening complications of surgery. The nurse should assess the client's vital signs, wound appearance, and laboratory results, and notify the physician immediately.
Choice B reason: This client has a chest tube to drain the pleural fluid and re-expand the lung. The amount of drainage is within normal limits and does not indicate an emergency. The nurse should monitor the client's respiratory status, oxygen saturation, and chest tube function.
Choice C reason: This client has a gunshot wound that may have caused tissue damage and bleeding. The dressing with 2 cm-sized dark red drainage may indicate fresh bleeding, but it is not excessive. The nurse should check the dressing for signs of infection, change it as ordered, and report any changes to the physician.
Choice D reason: This client has a Jackson-Pratt drain to collect the fluid from the surgical site after a mastectomy. The amount of serosanguineous fluid is expected and does not indicate a problem. The nurse should empty and measure the drain output, record it, and report any abnormalities to the physician.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: Recording the patient's pulse volume distal to the IV site is a nursing assessment that requires clinical judgment and cannot be delegated to the UAP.
Choice B Reason: Reapplying cold compresses to the site of the extravasation is a nursing intervention that requires clinical judgment and cannot be delegated to the UAP.
Choice C Reason: Disposing of the IV tubing after the infusion is discontinued is a routine task that does not require clinical judgment and can be delegated to the UAP.
Choice D Reason: Teaching the patient about the need to keep the extremity elevated is a nursing intervention that requires clinical judgment and cannot be delegated to the UAP.
Correct Answer is D
Explanation
Choice A Reason: This is not the best action because it does not address the conflict between the client and the healthcare provider. The nurse should advocate for the client's wishes and seek a resolution that respects them.
Choice B Reason: This is not an appropriate action because it disregards the client's request and may give false hope. The nurse should respect the client's autonomy and dignity.
Choice C Reason: This is not a sufficient action because it does not ensure that the healthcare provider will comply with the client's request. The nurse should also involve other resources to help resolve the ethical dilemma.
Choice D Reason: This is the best action because it involves an impartial group of experts who can help mediate the situation and protect the client's rights. The nurse should seek ethical consultation when there is a disagreement about end-of-life decisions.
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