Which client information is most important for the practical nurse (PN) to consider when providing instructions to the unlicensed assistive personnel (UAP) about providing morning care to a postoperative client?
Blood pressure of 144/84.
Oxygen saturation measurement of 95 to 96%.
Oriented to person only.
Urinary output of 50 mL/hour.
The Correct Answer is C
The correct answer is C. Oriented to person only.
Choice A rationale:
A blood pressure of 144/84 mmHg is slightly elevated but not critically high. While it is important to monitor, it does not immediately impact the instructions for morning care.
Choice B rationale:
An oxygen saturation measurement of 95 to 96% is within the normal range and indicates adequate oxygenation. This is important to monitor but does not require specific changes to morning care instructions.
Choice C rationale:
Being oriented to person only indicates a significant alteration in the client’s cognitive status, which is crucial for the UAP to be aware of. This affects the client’s ability to understand and follow instructions, and may require additional supervision and safety measures during care.
Choice D rationale:
A urinary output of 50 mL/hour is within the normal range (typically 30-50 mL/hour is considered adequate). While it is important to monitor, it does not necessitate immediate changes to morning care instructions.
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Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A,B,D,C
Explanation
= The correct sequence is: A. Perform standard hand washing, B. Put on disposable gown, D. Don a pair of procedure gloves, C. Remove gloves and gown in the room.
Choice A rationale:
Performing standard hand washing before donning personal protective equipment (PPE) is essential to ensure that the UAP's hands are clean before putting on gloves and gown.
Choice B rationale:
Putting on a disposable gown is the next step after hand washing to protect the UAP's clothing from potential contamination.
Choice D rationale:
Donning a pair of procedure gloves is the next step after putting on the gown to protect the UAP's hands from contact with potentially infectious material.
Choice C rationale:
Removing gloves and gown in the client's room is the last step in the sequence. This step ensures that any potential contaminants stay within the isolation room and do not spread to other areas of the facility.
Correct Answer is B
Explanation
The PN should not prioritize bringing a glucometer to the room in this situation. The client's unresponsiveness indicates a potential medical emergency that requires immediate action, and checking blood glucose levels is not the primary concern at this moment.
Choice C rationale:
Feeling for a carotid pulse is an essential step in assessing the client's circulation. However, it is not the first priority when the client is unresponsive. The PN should focus on obtaining emergency help first to ensure timely intervention.
Choice D rationale:
Checking the blood pressure can provide valuable information about the client's condition, but it is not the most critical step when dealing with an unresponsive client. Promptly seeking emergency assistance is more important to address the immediate concern.
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