When monitoring a client's abdominal incision, the practical nurse (PN) observes a large amount of sanguineous drainage on the dressing. Which client data collection should the PN complete first?
Temperature.
Pain scale.
Bowel sounds.
Blood pressure.
The Correct Answer is A
The correct answer is Choice A. Temperature. Choice A rationale:
The practical nurse (PN) should complete the data collection for temperature first. A large amount of sanguineous drainage on the abdominal incision dressing could indicate possible infection or a change in the client's condition. Elevated temperature may be an early sign of infection, which requires immediate attention and appropriate intervention.
Choice B rationale:
Assessing the pain scale is important, but it can be addressed after completing the data collection for temperature. Pain assessment is essential for providing appropriate pain management, but it is not the most urgent concern when there is a significant amount of drainage from the incision site.
Choice C rationale:
Checking bowel sounds is relevant in postoperative care, but it is not the priority at this moment. Abdominal incision drainage takes precedence as it may indicate a more critical issue that requires immediate attention.
Choice D rationale:
Monitoring blood pressure is essential, but it is not the most immediate concern in this scenario. A large amount of sanguineous drainage from the abdominal incision takes precedence over blood pressure monitoring at this time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice d. Powerful craving for more.
Rationale:
Cocaine withdrawal symptoms are primarily psychological and emotional, rather than physical. While some physical symptoms may occur, such as fatigue and muscle aches, the most prominent and concerning aspects of withdrawal are intense cravings for the drug.
Here's a breakdown of the other choices and why they are not as likely:
- Choice a. Elevated energy level:Cocaine is a stimulant,so during withdrawal,a person is more likely to experiencedecreased energy and fatigue.
- Choice b. High self-esteem:Cocaine use can initially boost self-esteem,but withdrawal often leads to feelings ofdepression, anxiety, and worthlessness.
- Choice c. Euphoria:Euphoria is one of the main effects of cocaine use,but during withdrawal,the opposite occurs,with individuals experiencingdysphoria, a state of intense negative emotions.
Therefore, the intense craving for more cocaine is the most characteristic behavioral symptom exhibited during cocaine withdrawal. This craving is driven by the brain's adaptation to the drug's presence and the disruption of dopamine and other neurotransmitter systems caused by withdrawal.
Additional Notes:
- The intensity of cocaine withdrawal symptoms can vary depending on several factors,including the severity and duration of cocaine use,individual differences in brain chemistry and genetics,and the presence of co-occurring mental health conditions.
- Seeking professional help for cocaine withdrawal is crucial to manage cravings and other symptoms effectively and increase the chances of successful recovery.
Correct Answer is D
Explanation
This is the factor that the PN should consider the most likely to increase the client's risk for falls because it can cause orthostatic hypotension, dizziness, or fainting, especially when the client changes position or gets up from bed or a chair. The PN should monitor the client's blood pressure and pulse before and after administering the medication and assist the client with ambulation and transfers.
A. An ankle ulcer that is healing slowly is not a major risk factor for falls and may not affect the client's mobility or balance.
B. History of alcohol abuse and cigarette smoking is not a major risk factor for falls unless the client is currently intoxicated or has a chronic lung disease that impairs oxygenation or cognition.
C. Recent weight gain of twenty pounds is not a major risk factor for falls unless it causes joint pain, edema, or difficulty moving.
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