The practical nurse (PN) finds a postoperative client lying in bed with an unsecured surgical dressing. After reinforcing the dressing, which follow-up assessment is most important for the PN to implement?
Vital sign measurement.
Fluid volume intake and output.
Volume of peripheral pulses.
Incisional pain scale rating.
The Correct Answer is A
This is the most important follow-up assessment for the PN to implement because it can detect signs of bleeding, infection, or shock that may result from the unsecured surgical dressing. The PN should monitor the client's blood pressure, pulse, temperature, and respiratory rate and report any abnormal changes.
B. Fluid volume intake and output is not the most important follow-up assessment for this client and may not reflect the current status of the client's fluid balance or blood loss.
C. Volume of peripheral pulses is not the most important follow-up assessment for this client and may not be affected by the unsecured surgical dressing unless it is located on a limb or near a major artery.
D. Incisional pain scale rating is not the most important follow-up assessment for this client and may not indicate the severity or cause of the client's pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.6"]
Explanation
Step 1: The medication is prescribed as 30 mg every 12 hours, which means it is given twice a day. So, the total daily dosage in mg is 30 mg × 2 = 60 mg.
Step 2: The medication is available in 30 mg per 0.3 mL. So, to find out how many mL correspond to 60 mg, we set up a proportion: (30 mg / 0.3 mL) = (60 mg / x mL). Solving for x gives x = (0.3 mL / 30 mg) × 60 mg = 0.6 mL.
Therefore, the practical nurse should administer 0.6 mL of the medication each day.
Correct Answer is C
Explanation
Correct Answer: C. Measure the next voiding, then palpate the client's bladder.
Choice A rationale:
Catheterizing the client for residual urine volume is not necessary at this point because the woman has recently given birth, and frequent urination is common during the postpartum period. Additionally, catheterization poses risks of infection, so it should be reserved for situations where it is clinically indicated.
Choice B rationale:
Evaluating for normal involution and massaging the fundus is not relevant in this context. Fundal massage is performed after childbirth to ensure the uterus contracts and prevents excessive bleeding. The woman's concern is about frequent urination, which does not require fundal massage.
Choice C rationale:
Measuring the next voiding and palpating the client's bladder is the most appropriate action. The woman's increased frequency of urination could be due to postpartum diuresis, a normal physiological process where the body eliminates excess fluid accumulated during pregnancy. By measuring the next voiding and palpating the bladder, the nurse can assess for bladder distension or retention, which could be signs of a problem.
Choice D rationale:
Obtaining a specimen for urine culture and sensitivity is not indicated in this situation. There is no evidence to suggest that the woman has a urinary tract infection or other urinary issues that would warrant a urine culture at this time.
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