A nurse is assisting in the care of a client who is 4 days postpartum and has endometritis. Which of the following interventions should the nurse anticipate will be included in the plan of care?
Cleanse the perineum with 0.9% sodium chloride after bowel movements
Obtain serial blood cultures.
Insert and maintain an indwelling urinary catheter.
Encourage the use of a sitz bath twice a day,
The Correct Answer is B
Rationale:
A. Cleanse the perineum with 0.9% sodium chloride after bowel movements: While perineal hygiene is important postpartum, cleansing with normal saline is more routine care and does not specifically target endometritis management.
B. Obtain serial blood cultures: Endometritis is a uterine infection that can lead to bacteremia or sepsis. Serial blood cultures help identify the causative organism and guide antibiotic therapy.
C. Insert and maintain an indwelling urinary catheter: Indwelling catheters increase the risk of urinary tract infections and are not routinely used unless there is urinary retention or other specific indications.
D. Encourage the use of a sitz bath twice a day: Sitz baths promote perineal comfort and hygiene but do not directly treat uterine infections like endometritis. They may be recommended for perineal pain but are not primary treatment for endometritis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Attempt to extinguish the fire before evacuating clients: The priority is client safety. Attempting to extinguish a fire should only be done if the fire is small, contained, and the area has been cleared. Evacuation takes precedence over suppression efforts.
B. Aim the spray of the fire extinguisher at the top of the fire: The correct technique is to aim at the base of the fire to effectively cut off the fuel source. Aiming at the top will not extinguish the fire and may waste the extinguisher’s contents.
C. Open nearby doors and windows when the fire alarm sounds: Opening doors and windows can cause the fire to spread more rapidly by feeding it with oxygen. Doors should remain closed to help contain the fire and reduce the spread of smoke.
D. Have ambulatory clients walk independently to a safe location: Encouraging ambulatory clients to move independently helps prioritize assistance for those who are immobile or require more support. This approach ensures a quicker, safer evacuation process.
Correct Answer is C
Explanation
Rationale:
A. Thoracotomy set: A thoracotomy set is used for emergency chest procedures, such as to relieve a pneumothorax or drain the pleural space. It is not relevant to a thyroidectomy, which involves the neck and airway rather than the thoracic cavity.
B. Vacuum assisted wound device: A vacuum-assisted wound device is used for chronic or large open wounds requiring negative pressure therapy. It is not indicated for fresh surgical incisions or preventive airway management following thyroid surgery.
C. Tracheostomy kit: A tracheostomy kit should be readily available at the bedside following thyroid surgery because of the risk of airway obstruction from swelling, bleeding, or damage to the recurrent laryngeal nerve. Immediate airway access may be needed in case of respiratory distress.
D. Tuning fork: A tuning fork is used in auditory and vibration assessments, such as during Rinne and Weber tests. It has no relevance to the immediate post-operative care of a client undergoing a thyroidectomy.
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