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 C
Explanation
Rationale:
A. Put a simple lock on the client's bedroom door: Locking the client's door could pose a safety risk, especially in the event of an emergency such as a fire. It also restricts the client's autonomy and may increase confusion or agitation in clients with Alzheimer's disease.
B. Give the client a barbiturate medication at bedtime: Barbiturates are not recommended for older adults due to their sedating effects and risk of dependence, falls, and worsening cognitive function. Non-pharmacologic strategies are preferred first in managing sleep disturbances.
C. Encourage the client to take frequent walks during the day: Physical activity during the day helps reduce nighttime restlessness and improve sleep patterns. Walking can also help regulate circadian rhythms, promote relaxation, and reduce wandering behavior at night.
D. Allow the client to nap for at least 1 hr during the day: Long daytime naps may disrupt the sleep-wake cycle, worsening insomnia and nighttime wandering. Limiting daytime napping and encouraging activity is more effective in promoting restful nighttime sleep.
Correct Answer is A
Explanation
Rationale:
A. The weights apply a pulling force continuously: Buck’s traction is a form of skin traction used to immobilize fractures and reduce muscle spasms. The weights must hang freely and provide a constant pulling force to maintain alignment and promote healing.
B. The boot allows active leg movement: In Buck’s traction, the affected leg should be immobilized. Active movement would interfere with the consistent traction force and compromise the effectiveness of the treatment.
C. The footplate rests against the foot of the bed: The client’s foot should not press against the bedframe or footplate, as this can counteract the traction force and cause improper alignment. There should be adequate space for traction to be effective.
D. The weights are just touching the floor: Weights should hang freely and never touch the floor. If they rest on the floor, the traction force is lost, defeating the purpose of the setup and potentially leading to complications.
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