Which client finding should the practical nurse (PN) report to the registered nurse (RN) immediately?
Oral ice chips 30 minutes eaten after vomiting postoperatively.
Inability to void 4 hours after discontinuing an indwelling catheter.
Coffee-ground secretions draining via nasogastric tube suction.
Ineffective pain management reported while using morphine PCA.
The Correct Answer is C
The correct answer is choice C. Coffee-ground secretions draining via nasogastric tube suction.
Choice A rationale:
Oral ice chips eaten 30 minutes after vomiting postoperatively could be considered normal in some cases. However, this finding may not require immediate reporting to the RN unless
other concerning symptoms are present. Choice B rationale:
The inability to void 4 hours after discontinuing an indwelling catheter is not an immediate concern. It's not uncommon for some clients to experience difficulty urinating initially after catheter removal. The client should be closely monitored, and the RN should be informed if the situation persists or worsens.
Choice C rationale:
This is the correct answer because coffee-ground secretions draining via nasogastric tube suction can indicate bleeding in the gastrointestinal tract, potentially from the stomach or esophagus. This finding requires immediate attention as it could be a sign of a serious condition and may require urgent intervention.
Choice D rationale:
Ineffective pain management reported while using morphine PCA is a concern but may not be as critical as the coffee-ground secretions. The PN should still report this finding to the RN for appropriate assessment and possible adjustment of pain management, but it may not warrant immediate reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
The risk of infection is not the priority nursing problem in this scenario. While the darkened membranes and smoky breath may be indicative of potential infection, addressing ineffective airway clearance is more urgent as it directly impacts the client's breathing and oxygenation.
Choice B rationale:
Ineffective airway clearance should be the priority nursing problem. Darkened membranes of the mouth and smoky breath suggest possible inhalation injury or airway obstruction.
Maintaining a patent airway is crucial for adequate oxygenation and to prevent further complications.
Choice C rationale:
Acute pain is not the priority nursing problem in this case. Although it is essential to address any discomfort the client may be experiencing, it takes a back seat to the more critical issue of ineffective airway clearance.
Choice D rationale:
Disturbed body image is not the priority nursing problem when the client has darkened mouth membranes and smoky breath. While it is important to address body image concerns, the immediate focus should be on managing and improving the client's airway clearance.
Correct Answer is D
Explanation
The correct answer is D. Electrolytes.
Choice A rationale: The white blood cell count (WBC) is typically reviewed for signs of infection or inflammation, but it is not directly related to numbness and tingling.
Choice B rationale: Hematocrit levels assess the proportion of red blood cells in the blood, which are not commonly associated with numbness and tingling.
Choice C rationale: Albumin and protein levels are important for nutritional status and overall health but are not directly associated with numbness and tingling.
Choice D rationale: Electrolytes are crucial for nerve function and muscle contractions. Abnormal levels of electrolytes (such as calcium, potassium, or sodium) can lead to symptoms like numbness and tingling in the extremities.
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