When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?

Low intermittent suction prescribed for the nasogastric tube is turned off.

A Hemovac drain is partially full of serous drainage and is not compressed.

The urinary catheter drainage bag is almost completely full of amber urine.

Oxygen is being administered via nasal cannula at 4 L/minute without humidification.

Answer and Explanation

The Correct Answer is D

A. This requires prompt attention but is not immediately life-threatening.

B.   This requires attention but does not pose an immediate threat to the client's condition.

C.   An almost completely full urinary catheter drainage bag requires attention but does not pose an immediate threat to the client's condition.
D.   Administering oxygen without humidification could lead to mucosal dryness and damage, and should be addressed promptly.

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Correct Answer is B

Explanation

A. Elevating the head of the bed can help improve oxygenation but is not directly related to managing sepsis.
B. Monitoring blood glucose levels is crucial in sepsis management as hyperglycemia can exacerbate the inflammatory response.
C. While intake and output monitoring is important, it is not the priority in the early management of sepsis.
D. Assessing warmth of extremities is important but not the most critical intervention in managing sepsis.

A. Weigh the client and report any weight gain. B. Assess the client for weakness and fatigue. C. Report any client mention of pain or discomfort. D. Note and report the client's food and liquid intake during meals and snacks.

Correct Answer is ["A","C","D"]

Explanation

A. Weighing the client and reporting weight gain is within the scope of UAP and important for monitoring fluid retention and weight changes in Cushing's syndrome.

B. Assessing for weakness and fatigue requires clinical judgment and should be performed by a nurse.
C. Reporting any client mention of pain or discomfort is appropriate for UAP, as it involves relaying information to the nurse for further assessment.
D. Noting and reporting the client's food and liquid intake is appropriate for UAP and necessary for monitoring nutritional status and intake.
E. Evaluating sleep disturbances involves assessment skills and should be performed by a nurse.

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When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with pneumonia who now develops initial signs of septic shock and multi-organ failure. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care?

Correct Answer is B

Explanation

The nurse is managing the care of a client with Cushing's syndrome. What intervention(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

The nurse is caring for an immobile client after spinal surgery. Which action is most important for the nurse to take to prevent postoperative complications?

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A nurse is caring for a 4-year-old child who is resistant to taking medication. Which of the following strategies should the nurse use to elicit the child's cooperation?

After receiving report on an inpatient acute care unit, which client should the nurse assess first?