While the practical nurse (PN) and unlicensed assistive personnel (UAP) are turning a client with an abdominal incision, the client's incision eviscerates. Which task is best for the PN to assign to the UAP?
Keep the client calm.
Gather supplies.
Cover the wound.
Reposition the client.
The Correct Answer is B
A. While it’s important to keep the client calm, this task may not be the most critical or appropriate for a UAP in an emergency situation. The nurse typically leads in managing the client's immediate needs.
B. This is a crucial task because the PN will need sterile supplies (e.g., sterile saline, dressings) to manage the evisceration. The UAP can efficiently gather these supplies, allowing the PN to focus on assessing the client and providing immediate care. This delegation is appropriate because it helps expedite the response to a critical situation.
C. Covering the wound is a critical step in managing evisceration, which should be performed by the PN to ensure it is done correctly and to maintain sterile technique. The PN is responsible for the clinical management of the emergency.
D. Repositioning the client could exacerbate the situation or delay necessary interventions. The PN must assess and manage the evisceration while ensuring the client remains as stable as possible.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Body temperature is not directly relevant to the administration of zolpidem. Zolpidem is a sleep aid, so assessing body temperature is not necessary for this medication.
B. Bowel sounds are important for gastrointestinal assessments but are not related to the immediate considerations for zolpidem administration.
C. Assessing mental status is crucial before administering zolpidem because this medication can cause side effects like drowsiness, confusion, or impaired cognition. Ensuring the client’s mental status is appropriate helps prevent adverse effects.
D. Skin integrity is important for general health assessments but is not specifically relevant before administering a sleep aid like zolpidem.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
Explanation
Respiratory acidosis
The laboratory results show a pH of 7.31, which is below the normal range of 7.35-7.45, indicating acidosis. Additionally, the PaCO2 is elevated at 51 mmHg, which is above the normal range of 35-45 mmHg, pointing towards a respiratory cause of the acidosis.
Carbon dioxide retention
During the submersion, the child likely experienced impaired ventilation, leading to hypoventilation and subsequent retention of carbon dioxide. This retention of CO2 contributes to respiratory acidosis.
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