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: Instructing UAPs to transfer all non-ambulatory clients via wheelchairs is not a good intervention, as it may expose the clients and the UAPs to smoke and fire, and cause panic and congestion in the hallways. The charge nurse should follow the RACE protocol (Rescue, Alarm, Contain, Extinguish), which means rescuing only those clients who are in immediate danger, and containing the fire by closing doors and windows.
Choice B Reason: Instructing the nursing staff to evacuate ambulatory clients to the nearest fire exits is not a good intervention, as it may also expose the clients and the staff to smoke and fire, and interfere with the fire
department's efforts. The charge nurse should follow the RACE protocol, which means evacuating only as a last resort, and only after receiving instructions from the fire department.
Choice C Reason: Shutting all doors to client rooms and telling everyone to stay in their rooms until the fire
department arrives is the best intervention, as it follows the RACE protocol, which means containing the fire by closing doors and windows, and extinguishing it if possible with a fire extinguisher. This intervention also helps protect the clients and staff from smoke inhalation and fire spread, and allows the fire department to access and control the fire.
Choice D Reason: Announcing in a calm voice that all visitors should proceed immediately to the first floor via the service elevators is not a good intervention, as it may endanger the visitors and cause more damage. The charge nurse should follow the RACE protocol, which means alarming others by activating the fire alarm system and calling 911. The charge nurse should also instruct visitors not to use elevators during a fire, as they may malfunction or trap them inside.
Correct Answer is B
Explanation
Choice A Reason: The ability to update the equipment each year may be desirable, but not the most important question to consider. Updating the equipment may incur additional costs and may not be necessary or feasible depending on the type and function of the equipment.
Choice B Reason: The number of departments that can use the equipment is the most important question to
consider, as it reflects the potential impact and benefit of the equipment for the organization. The more departments that can use the equipment, the more efficient and cost-effective it will be.
Choice C Reason: The cost of equipment is an important question to consider, but not the most important one. The cost of equipment should be compared with the expected benefits and outcomes of using the equipment, not just in terms of monetary value, but also in terms of quality of care and patient satisfaction.
Choice D Reason: The need for annual repair is an important question to consider, but not the most important one. The need for annual repair may indicate the reliability and durability of the equipment, but it may also depend on the frequency and intensity of use, and the availability and accessibility of maintenance services.
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