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.

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Correct Answer is D

Explanation

d. Escort the client to a calm and quiet place.

The PN should use a calm and firm approach to de-escalate the situation and remove the client from the stressful environment. This can help prevent further agitation and potential violence.

The other options are not correct because:

Instructing a UAP to stay with the client may not be eﬀective or safe, as the UAP may not have the skills or training to handle an agitated client.
Notifying the client's healthcare provider is not a priority action, as it does not address the immediate safety of the client and others.
Administering a PRN medication for agitation may be indicated, but it is not the first action. The PN should try non- pharmacological interventions first, unless there is an imminent risk of harm.

A. Review the client's expectations of elimination after surgery. B. Verify that the client had nothing by mouth (NPO) for the past 24 hours. C. Ask the client if he finished the bowel sterilization prescription. D. Determine if this is the first indwelling catheter the client has had.

Correct Answer is A

Explanation

This is the best action for the PN to implement because it addresses the client's question and provides an opportunity to educate the client about the fecal diversion surgery and its outcomes. The PN should review the type, location, and appearance of the surgical opening (stoma) and explain how it will aﬀect the client's elimination and body image.

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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

A client in the psychiatric unit's dayroom is becoming agitated, talking incessantly, and starting to yell and swear at the other clients. Which action should the practical nurse (PN) implement first?

Correct Answer is D

Explanation

The practical nurse (PN) is assisting with preparation of a client for fecal diversion surgery. While inserting an indwelling urinary catheter, the client asks if the surgical opening will be visible. Which action should the PN implement?

Correct Answer is A

Explanation

The charge nurse brings a #18 urinary catheter with a 30 mL balloon to the practical nurse (PN) who is preparing to insert a catheter in a female client who weighs 50 kg. Which action should the PN take first?

What is most important for the practical nurse (PN) to include when performing pain assessment after giving an analgesic?

A client who had knee replacement surgery receives a prescription for enoxaparin 30 mg subcutaneously every 12 hours for 10 days. The medication is available in 30 mg per 0.3 mL prefilled syringes. How many mL should the practical nurse (PN) administer each day? (Enter numerical value only.).

The practical nurse (PN) prepares to remove a client's saline lock. Which supplies should the PN gather? (Select all that apply.)

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The practical nurse (PN) is charting vital signs on a hand-writen ﬂow sheet and realizes that an error has been made. What should the PN do to rectify this error?

A client is receiving palliative care, and death is anticipated within the next 24 hours. The practical nurse (PN) observes that the client's legs have a mottled appearance. What should the PN apply to the client's legs?