The practical nurse (PN) receives change of shift report on a postpartum unit. Which client should receive the PN's attention first?
A client who needs to ambulate to the bathroom for the first time since the birth of her infant.
A client prepared for discharge who has a question about the teaching she received the day before.
A client with twins who is tired and would like her babies returned to the newborn nursery.
A post cesarean client with a prescription to have her indwelling urinary and intravenous
The Correct Answer is A
A. A client who needs to ambulate for the first time since delivery requires the PN’s immediate attention to ensure safety and prevent complications such as orthostatic hypotension or falls.
B. A client prepared for discharge who has a question about teaching is important but does not take precedence over immediate safety concerns related to the client’s physical activity.
C. A tired client with twins who would like her babies returned to the nursery is important for the client’s well-being, but it is not as urgent as ensuring the safety of a postpartum client beginning to ambulate.
D. Removing indwelling urinary and intravenous catheters is important but not as urgent as ensuring the safety of a client ambulating for the first time after birth.
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Related Questions
Correct Answer is A
Explanation
A. Reporting any foot injury or sore that does not readily heal is the most crucial instruction for minimizing long-term complications in diabetes management. Poor circulation and neuropathy in diabetic patients can lead to serious complications from minor foot injuries, so prompt medical evaluation is essential for preventing severe outcomes.
B. Drying feet thoroughly between toes is important for preventing fungal infections, but it is a standard part of foot care rather than a primary measure for preventing long-term complications like ulcers or infections.
C. Ensuring that shoe size fits to minimize rubbing and blisters is important for foot health, but it is not as critical as promptly addressing any injuries or sores that may arise.
D. Monitoring fingerstick glucose daily for tight control is necessary for diabetes management but does not directly address foot care issues. It is important for overall disease management but not specifically for immediate foot care concerns.
Correct Answer is C
Explanation
A. Observing for signs of pain or discomfort during the treatment is not a direct method for evaluating ondansetron’s effectiveness. Ondansetron is used to prevent nausea and vomiting, not to manage pain.
B. While assessing vital signs is important for overall monitoring, it does not specifically measure the effectiveness of ondansetron for preventing nausea and vomiting.
C. Monitoring for nausea or vomiting following the treatment is the most direct way to evaluate the effectiveness of ondansetron. The primary goal of ondansetron is to prevent or reduce these symptoms associated with chemotherapy.
D. Evaluating if the client feels calm and relaxed is not a measure of ondansetron’s effectiveness. The focus should be on the medication’s ability to prevent nausea and vomiting rather than the client's emotional state before treatment.
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