The practical nurse (PN) is providing care for a client who is ordered nothing by mouth (NPO) after a small bowel resection. The client's nasogastric (NG) tube is connected to low intermitent suction. The client reports dizziness and tingling in digits.

Which assessment finding by the PN should be reported to the healthcare provider?

Hyperactive bowel sounds on assessment.

Heart rate of 90 beats per minute with premature ventricular contractions (PVCs) noted on telemetry.

Hypoactive bowel sounds on assessment

Regular heart rate of 100 beats per minute on telemetry

Answer and Explanation

The Correct Answer is B

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Correct Answer is D

Explanation

Choice A rationale: While it is important to monitor the fetal heart rate, it does not directly address the client's immediate need to empty her bladder.

Choice B rationale: Obtaining a straight catheter kit to empty her bladder could be considered if the client is unable to void on her own, but it is not the first line of action if the client is able to ambulate.

Choice C rationale: Checking the perineum for changes in "show" or discharge is part of ongoing labor monitoring, but it does not address the client's immediate request.

Choice D rationale: Assisting the client up to the bathroom is appropriate. Ambulating to the bathroom is safe given the unchanged vaginal exam, and allowing the client to empty her bladder can help maintain bladder function and comfort.

A. Limiting the client's fluid intake to avoid hemodilution. B. Avoiding the client's exposure to cold temperature. C. Initiation of changes in infection control measures. D. Increasing the client's dietary servings of fruits and vegetables.

Correct Answer is ["C"]

Explanation

The correct answer is choice C. Initiation of changes in infection control measures.

Choice A rationale:

Limiting the client’s fluid intake to avoid hemodilution is not relevant to managing a decreased ANC. Hemodilution is not a concern in this context, and fluid intake should generally be maintained to support overall health.

Choice B rationale:

Avoiding exposure to cold temperatures is not directly related to managing a decreased ANC. While keeping the client comfortable is important, it does not address the increased risk of infection associated with neutropenia.

Choice C rationale:

Initiation of changes in infection control measures is crucial when a client’s ANC decreases. Neutropenia increases the risk of infections, so enhanced infection control practices, such as strict hand hygiene, use of protective isolation, and monitoring for signs of infection, are essential to protect the client.

Choice D rationale:

Increasing the client’s dietary servings of fruits and vegetables is generally beneficial for overall health but does not specifically address the immediate risks associated with a decreased ANC. In fact, certain fresh fruits and vegetables might need to be avoided if they pose a risk of introducing pathogens.

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

While receiving report for a client with carcinoma in situ of the left breast, the practical nurse (PN) reviews a pending lab report and notices the client's Absolute Neutrophil Count (ANC) has decreased. Which changes should the PN anticipate to be included in the client's plan of care?

Correct Answer is ["C"]

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?

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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?