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
The correct answer is choice B: Children need time to actively explore their environment. Choice A rationale:
Playpens do provide a sense of security for the child, but confining the child solely to the playpen might hinder their developmental needs. While it is essential to have a safe space for a toddler, children also require opportunities to explore and engage with their environment actively.
Choice B rationale:
The practical nurse (PN) should use this rationale when responding to the parent. Children, especially toddlers, learn and develop crucial skills through active exploration of their environment. Being confined to a playpen for extended periods may limit their opportunities for learning, hinder their physical development, and restrict social interaction, which are essential aspects of their growth.
Choice C rationale:
While playpens can provide a safe environment for a toddler when used appropriately and under supervision, keeping the child confined for the sole purpose of preventing dirtiness is not recommended. Overusing playpens can hinder a child's natural curiosity and desire to explore, potentially affecting their overall development.
Choice D rationale:
While over-concern about appearance can be harmful in some contexts, it is not directly related to the child being kept in a playpen to avoid getting dirty. The primary concern here is about providing the child with adequate opportunities for exploration, growth, and development, rather than focusing solely on appearance.
Correct Answer is A
Explanation
The correct answer is choice A. Consecutive evening serum glucose greater than 260 mg/dL.
Choice A rationale:
A consecutive evening serum glucose greater than 260 mg/dL indicates persistent hyperglycemia. Inadequate NPH insulin dosage may lead to consistently high blood glucose levels, which can result in various complications.
Choice B rationale:
The complaint of cold feet and numbness is not a specific indicator of inadequate insulin dosage. Neuropathy and circulation issues can occur with poorly controlled diabetes, but they are not solely indicative of inadequate insulin.
Choice C rationale:
Nausea in the morning, even with the ability to eat breakfast, does not necessarily point to inadequate insulin dosage. It could be due to various factors, including dietary choices or other medical conditions.
Choice D rationale:
The wound on the ankle that starts to drain and becomes painful is not a specific sign of inadequate insulin dosage. Poorly controlled diabetes can lead to delayed wound healing, but it does not necessarily indicate that the current insulin dosage is insufficient.
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