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 A
Explanation
The correct answer is Choice A:
Assist in turning the client to one side. Choice A rationale:
When preparing a client with obstructive sleep apnea for sleep, the practical nurse (PN) should assist the client in turning to one side. This position is known as the lateral position and can be beneficial for clients with obstructive sleep apnea. Lying on one's side can help to reduce the likelihood of airway obstruction and minimize the occurrence of apnea (pauses in breathing) during sleep. This position promotes better airflow and can improve the client's overall sleep quality.
Choice B rationale:
Keeping oral suction equipment nearby (Choice B) might be appropriate for clients with respiratory issues or a risk of airway obstruction. However, it is not the best action for a client with obstructive sleep apnea. Sleep apnea primarily involves upper airway collapse, not excessive secretions or obstructions in the oral cavity.
Choice C rationale:
Offering to bring the client a sleeping pill (Choice C) is not an appropriate action for a client with obstructive sleep apnea. Sleep apnea is characterized by repeated episodes of blocked or restricted airflow during sleep. Sedative medications can further relax the muscles in the airway, worsening the condition and potentially leading to more severe apnea.
Choice D rationale:
Placing a cool air humidifier in the room (Choice D) may be helpful for clients who experience dryness or congestion in the airways during sleep. However, it is not specifically indicated for obstructive sleep apnea. While humidifiers can be beneficial for some sleep-related issues, they do not address the underlying cause of sleep apnea.
Correct Answer is C
Explanation
Instruct the UAP to lower the bed for safety.
This is the best action for the PN to take because it ensures the client's safety and prevents potential falls or injuries. The PN should also educate the UAP on the importance of lowering the bed when providing care to a bedfast client.
A. Assuming care of the client immediately is not necessary and may undermine the UAP's confidence and competence.
B. Remaining in the room to supervise the UAP is not appropriate and may interfere with the client's privacy and dignity.
D. Determining if the UAP would like assistance is not a priority and may not address the safety issue.
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