Sensory system NCLEX Questions questions published by www.nursingwork.in
Question No 1: During the initial assessment of a patient, the nurse observes the presence of bright red drainage on the eye dressing. Which of the following should be the nurse’s first action?
A. Note the amount of drainage on the client’s record
B. Continue to monitor the vital signs and pain
C. Report the findings to the physician
D. Mark the drainage on the dressing and monitor the amount and color
Answer: C. Report the findings to the physician
Bright red drainage on the dressing may indicate hemorrhage and must be reported to the physician immediately. Although monitoring vital signs and the client’s pain and recording the amount and color of the drainage are all important interventions, reporting the finding is the priority so emergency measures can be instituted
Question No 1: During the initial assessment of a patient, the nurse observes the presence of bright red drainage on the eye dressing. Which of the following should be the nurse’s first action?
A. Note the amount of drainage on the client’s record
B. Continue to monitor the vital signs and pain
C. Report the findings to the physician
D. Mark the drainage on the dressing and monitor the amount and color
Answer: C. Report the findings to the physician
Bright red drainage on the dressing may indicate hemorrhage and must be reported to the physician immediately. Although monitoring vital signs and the client’s pain and recording the amount and color of the drainage are all important interventions, reporting the finding is the priority so emergency measures can be instituted