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 B
Explanation
PVCs are abnormal heartbeats that occur when a ventricle contracts earlier than expected. They can indicate electrolyte imbalance, such as hypokalemia, which can result from NG suctioning. The PN should report this finding to the healthcare provider, as it may require treatment or adjustment of the suctioning.
The other options are not correct because:
A. Hyperactive bowel sounds on assessment may indicate increased peristalsis or bowel obstruction, but they are not related to the client's symptoms or NG suctioning.
C. Hypoactive bowel sounds on assessment may indicate decreased peristalsis or ileus, which are expected after bowel surgery and do not require immediate intervention.
D. Regular heart rate of 100 beats per minute on telemetry may indicate tachycardia, which can have various causes, but it is not as concerning as PVCs in this context.
Correct Answer is C
Explanation
The correct answer is choice C. Report the findings to the charge nurse. Choice A rationale:
Encouraging the client to drink fluids is not the priority in this situation. While hydration is important, the client's symptoms of muscle soreness, fatigue, and warm skin might indicate a potential adverse reaction to the statin medication, which requires immediate attention.
Choice B rationale:
Monitoring the client's serum lipid levels is not the priority at this moment. The client's current symptoms suggest a possible adverse reaction to the statin medication, and waiting for lipid level results may delay necessary interventions.
Choice C rationale:
Reporting the findings to the charge nurse is the priority action. The client's symptoms could be signs of rhabdomyolysis, a severe and potentially life-threatening condition where muscle breakdown releases toxic substances into the bloodstream. The charge nurse needs to be informed promptly so that appropriate interventions can be initiated.
Choice D rationale:
Administering a PRN dose of acetaminophen is not the priority in this situation. Acetaminophen may help with pain relief, but it will not address the potential underlying issue of muscle soreness and fatigue related to the statin medication.
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