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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

The Herpes zoster (shingles) vaccination is recommended for adults aged 60 years and older, regardless of whether they have had shingles or chicken pox before. The vaccine can reduce the risk of developing shingles and its complications, such as postherpetic neuralgia.

The other options are not correct because:

A. The vaccine is useful even if the person has had a case of shingles before, as shingles can recur in some people. The vaccine can prevent or reduce the severity of future episodes.

C. The person needs to get this vaccination even if they have had chickenpox, as shingles are caused by the reactivation of the same virus that causes chickenpox (varicella-zoster virus). The vaccine can boost the immunity against the virus and prevent it from reactivating.

D. The vaccination does not minimize outbreaks of cold sores, as cold sores are caused by a diﬀerent virus (herpes simplex virus). The vaccine has no eﬀect on this virus or its symptoms.

A. Turn the infant onto the right side. B. Give oxygen by positive pressure C. Suction the oral and nasal passages. D. Stimulate the infant to cry.

Correct Answer is C

Explanation

The correct answer is choice C. Suction the oral and nasal passages.

Choice A rationale:

Turning the infant onto the right side may not be the most appropriate intervention for cyanosis caused by regurgitation. Cyanosis signifies a lack of oxygen, and simply changing the infant's position might not address the underlying issue.

Choice B rationale:

Giving oxygen by positive pressure is not the immediate intervention needed for regurgitation-induced cyanosis. While administering oxygen is important, the first step should involve clearing the airway to ensure proper oxygenation.

Choice C rationale:

Suctioning the oral and nasal passages is crucial in this situation as the cyanosis is likely due to the infant's airway being obstructed by regurgitated material. Clearing the airway can restore normal breathing and oxygenation.

Choice D rationale:

Stimulating the infant to cry is not the appropriate action when cyanosis is present. Cyanosis indicates a serious problem with oxygenation, and crying may worsen the situation by further compromising the infant's breathing.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult female asks the practical nurse (PN) if she should get a Herpes zoster (shingles) vaccination because she gets cold sores on her mouth when she is sick or stressed. Which response should the PN provide?

Correct Answer is B

Explanation

A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. Which immediate intervention should the practical nurse (PN) implement?

Correct Answer is C

Explanation

A 15-year-old adolescent male with a mild mental disability is hospitalized for minor surgery and tells the practical nurse (PN), "Wow! You have big breasts." Which response is best for the PN to provide?

The practical nurse (PN) administers an injection using a syringe with a retractable needle. After the needle is removed from the client's skin, the needle does not retract, and the PN gets stuck in the finger with the used needle. What action should the PN take first?

Prior to an invasive examination of a hospitalized client, a consent form should be obtained. Which action best describes the responsibility of the practical nurse (PN)?

An older male client complains to the practical nurse (PN) during his annual physical exam that he is too tired to mow the lawn. Which response should the PN offer?

During the past 30 days, an elderly client has exhibited a progressively decreasing appetite, is spending increasing amounts of the daytime hours in bed, and refuses to participate in planned daytime activities. Which action should the practical nurse (PN) take?

The practical nurse (PN) is reinforcing dietary instructions with a client who has renal disease regarding the need to limit salt intake. Which selections for a lunch meal indicate to the PN that the client is following the diet plan? (Select all that apply.).