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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

This is the most important information for the PN to ask because it assesses the client's risk for self-harm and suicidal ideation. The client's statements indicate hopelessness, low self-esteem, and impaired functioning, which are potential warning signs of suicide. The PN should ask the client directly about any thoughts or plans of harming themselves and provide support and safety measures as needed.

A. Questioning about which rituals are most often used to reduce anxiety is not a priority and may reinforce the client's compulsive behavior.

B. Asking if the obsessions and compulsions interfere with sleep is not a priority and may not address the client's emotional distress.

D.Determining what makes the client think people are laughing is not a priority and may not be helpful for the client's perception of reality.

A. Limiting the client's fluid intake to avoid hemodilution. B. Avoiding the client's exposure to cold temperature. C. Initiation of changes in infection control measures. D. Increasing the client's dietary servings of fruits and vegetables.

Correct Answer is ["C"]

Explanation

The correct answer is choice C. Initiation of changes in infection control measures.

Choice A rationale:

Limiting the client’s fluid intake to avoid hemodilution is not relevant to managing a decreased ANC. Hemodilution is not a concern in this context, and fluid intake should generally be maintained to support overall health.

Choice B rationale:

Avoiding exposure to cold temperatures is not directly related to managing a decreased ANC. While keeping the client comfortable is important, it does not address the increased risk of infection associated with neutropenia.

Choice C rationale:

Initiation of changes in infection control measures is crucial when a client’s ANC decreases. Neutropenia increases the risk of infections, so enhanced infection control practices, such as strict hand hygiene, use of protective isolation, and monitoring for signs of infection, are essential to protect the client.

Choice D rationale:

Increasing the client’s dietary servings of fruits and vegetables is generally beneficial for overall health but does not specifically address the immediate risks associated with a decreased ANC. In fact, certain fresh fruits and vegetables might need to be avoided if they pose a risk of introducing pathogens.

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Which client finding should the practical nurse (PN) report to the registered nurse (RN) immediately?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

While receiving report for a client with carcinoma in situ of the left breast, the practical nurse (PN) reviews a pending lab report and notices the client's Absolute Neutrophil Count (ANC) has decreased. Which changes should the PN anticipate to be included in the client's plan of care?

Correct Answer is ["C"]

Explanation

The practical nurse (PN) observes a client’s initial postoperative dressing, which is saturated with serosanguinous fluid, and a drainage device that appears partially compressed. Which follow-up actions should the PN implement? (Select all that apply.).

When performing a focused gastrointestinal system assessment, the practical nurse (PN) asks a male client when his last bowel movement occurred. The client answers, "Three days ago.”. Which action should the PN implement first?

A client is being treated for hepatic failure. On examination, the client has an elevated pulse rate and exhibited changes in mental status. Which intervention in the plan of care should the practical nurse (PN) implement?

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Which statement by an older female client who lost her spouse two years ago should indicate to the practical nurse (PN) that the client may need bereavement counseling?

The practical nurse (PN) is assigning care for a group of clients on the urology medical unit. Which client care interventions should the PN assign to the unlicensed assistive personnel (UAP)? (Select all that apply.).

The practical nurse (PN) is caring for a client who has darkened membranes of the mouth and a smoky breath. Which priority nursing problem should the PN include in the plan of care?