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 C
Explanation
This is the best action for the PN to take because it provides reality orientation and helps the client cope with the change in environment. The client may be experiencing acute confusion or delirium due to stress, medication, infection, or other factors. The PN should remind the client of the date, time, and place frequently and use other strategies such as calendars, clocks, and familiar objects to reduce confusion.
A. Documenting the client's loss of memory in the record is not enough and does not address the client's needs.
B. Notifying the family of the change in the client's condition is not a priority and may not be necessary if the confusion is temporary or reversible.
D. Encouraging the client to rest during the day is not appropriate and may worsen the confusion or disrupt the sleep-wake cycle.
Correct Answer is B
Explanation
This is the best intervention for the PN to implement because it relieves the muscle spasm and reduces the pain of a leg cramp. Leg cramps are common during pregnancy and labor due to changes in calcium levels, fluid balance, or pressure on nerves and blood vessels.
A. Massaging the calf and foot is not recommended because it may increase pain or cause injury to the muscle or nerve.
C. Checking the pedal pulse in the affected leg is not necessary unless there is a suspicion of vascular compromise or thrombosis, which are unlikely causes of a leg cramp.
D. Elevating the leg above the heart is not helpful because it may impair blood flow or increase pressure on the nerve or muscle.
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