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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
- Clean the site using sterile gauze and sterile water.
- Indicated: The turban dressing should be changed using sterile techniques to prevent infection and ensure proper wound care.
- Place client in a private room.
- Not Indicated: The client is already on contact precautions for MRSA, so the private room is a general requirement and not a specific intervention for the dressing change.
- Avoid hand sanitizer after the procedure.
- Not Indicated: Hand sanitizer is typically used before and after procedures. For MRSA contact precautions, hand hygiene is critical, and proper hand washing or using hand sanitizer is recommended after the procedure.
- Place the soiled dressing in a red biohazard bag.
- Indicated: The soiled dressing is considered contaminated and should be disposed of in a red biohazard bag to prevent the spread of infection.
- Use sterile gloves to remove the old dressing.
- Indicated: Sterile gloves are required for removing and replacing the dressing to maintain a sterile field and prevent infection.
Correct Answer is B
Explanation
A. Reviewing the blood pressure measurement is not the primary concern here; the issue is that the UAP is using the incorrect arm for the measurement.
B. The blood pressure should be measured on the non-operative side. Measuring on the operative side can cause discomfort, potential injury, or interfere with the healing process.
C. Elevating the arm after recording the blood pressure is not a standard requirement post-mastectomy. The immediate concern is the proper measurement site for the blood pressure.
D. A manual blood pressure cuff is not required for accuracy in this situation; the key issue is to use the non-operative arm for measurement.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.