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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Assign the remainder of medication administration to another PN who is performing treatments.
Choice A rationale:
Asking unlicensed assistive personnel (UAP) to give medications to their assigned residents is not the best action to take in this situation. Medication administration requires a certain level of training and knowledge to ensure safe and accurate delivery. UAPs may not have the appropriate training and legal authorization to administer medications, which could lead to potential errors and harm to the residents.
Choice B rationale:
Documenting why all the medications were not given to each resident is not sufficient to address the issue at hand. While documentation is essential for record-keeping and communication, it does not resolve the problem of medication administration being left incomplete. The priority should be finding a qualified person to administer the remaining medications.
Choice C rationale:
This is the correct answer because assigning the remainder of medication administration to another PN who is performing treatments ensures that qualified and trained personnel are handling the medication administration. This PN is likely familiar with medication protocols and safety measures, reducing the risk of errors.
Choice D rationale:
Denying the medication aide's request to leave before all medications are given might not be practical if the aide is genuinely unwell or unable to continue working safely. The focus should be on ensuring that medication administration is completed by qualified staff rather than forcing the sick aide to stay.
Correct Answer is D
Explanation
Observe the UAP's technique and communication skills during the bath.
The PN should directly observe the UAP's performance and provide feedback and guidance as needed. This can help ensure that the UAP follows the standards of care and respects the client's dignity and preferences.
The other options are not correct because:
- Asking another UAP to help the orientee may not be appropriate or necessary, as it may interfere with the orientation process and create confusion or conflict.
- Verifying with the client that the bath was complete and thorough may not be sufficient or reliable, as the client may not be able to assess the quality of care or may not want to complain.
- Inspecting the client's skin near the end of the bathing procedure may not be timely or comprehensive, as it may miss some aspects of care or some problems that occurred during the bath.
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