A client is admitted to the postpartum unit and tells the nurse she had rheumatic fever as a child, which resulted in some "heart damage." The nurse knows that this client is at particular risk for developing heart failure during the immediate postpartum period. Based on this client's history, which nursing problem has the highest priority?
Sleep deprivation.
Fluid volume excess
Nausea and vomiting
Risk for infection.
The Correct Answer is B
A. Sleep deprivation:
While sleep is important for overall well-being, it may not be the top priority in this case. Fluid volume excess, given the client's cardiac history, poses a more immediate threat to health.
B. Fluid volume excess:
Clients with heart damage are prone to heart failure, and managing fluid balance is crucial. Excess fluid can worsen cardiac function, making this the priority concern.
C. Nausea and vomiting:
While nausea and vomiting are significant concerns, they might not be as directly related to the client's cardiac history as fluid volume excess. However, if severe, it could contribute to fluid imbalance.
D. Risk for infection:
Infection is a concern for postpartum clients, but in this case, the client's history of rheumatic fever and heart damage takes precedence. The priority is to prevent complications related to heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["450"]
Explanation
- To calculate the infusion rate, use the formula:
(mL of solution / grams of drug) x (grams ordered / minutes to infuse) x 60
- In this case, the formula becomes: (500 mL / 20 g) x (6 g / 20 min) x 60
- Simplify and solve: (25 mL / g) x (0.3 g / min) x 60
- The answer is 450 mL/hour
- The nurse should set the infusion pump at 450 mL/hour
Correct Answer is ["12"]
Explanation
To solve this problem, the nurse needs to convert the units of oxytocin from units to milliunits.
One unit of oxytocin is equal to 1000 milliunits, so 10 units of oxytocin is equal to 10,000 milliunits.
- The concentration of oxytocin in the solution is 10,000 milliunits per 1000 mL, or 10 milliunits per mL.
- To deliver 2 milliunits per minute, the nurse needs to infuse 0.2 mL per minute of the solution.
- To convert from mL per minute to mL per hour, the nurse needs to multiply by 60 minutes per hour.
- Therefore, the nurse should program the infusion pump to deliver 0.2 x 60 = 12 mL per hour of the solution.
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