The practical nurse (PN) finds a postoperative client lying in bed with an unsecured surgical dressing as seen in the picture. 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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

This is the factor that the PN should consider the most likely to increase the client's risk for falls because it can cause orthostatic hypotension, dizziness, or fainting, especially when the client changes position or gets up from bed or a chair. The PN should monitor the client's blood pressure and pulse before and after administering the medication and assist the client with ambulation and transfers.

A. Instruct the mother to play with the child for stimulation and distraction. B. Administer a dose of acetaminophen as needed. C. Monitor the child's oxygen saturation level via pulse oximetry. D. Encourage the child to drink adequate amounts of ﬂuids.

Correct Answer is C

Explanation

Croup is a respiratory infection that causes inﬂammation and narrowing of the airway, resulting in a barking cough, hoarseness, and stridor. The PN should monitor the child's oxygen saturation level via pulse oximetry, as it can indicate the severity of the airway obstruction and the need for supplemental oxygen or other interventions.

The other options are not correct because:

A. Instructing the mother to play with the child for stimulation and distraction may worsen the child's condition, as it can increase his respiratory demand and anxiety.

B. Administering a dose of acetaminophen as needed may help reduce fever or pain, but it does not address the underlying cause of croup or improve airway patency.

D. Encouraging the child to drink adequate amounts of ﬂuids may help prevent dehydration and thin the secretions, but it does not relieve the inﬂammation or narrowing of the airway.

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The practical nurse (PN) finds a postoperative client lying in bed with an unsecured surgical dressing as seen in the picture. After reinforcing the dressing, which follow-up assessment is most important for the PN to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) reviews the history of an older adult who is newly admitted to a long term care facility. Which factor in the resident's history should the PN consider the most likely to increase the client's risk for falls?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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