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,

Answer and Explanation

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.

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Correct Answer is A

Explanation

Rationale:

A. Maintain the client in high-Fowler's position: Placing the client in high-Fowler's position improves lung expansion and decreases pulmonary congestion by lowering venous return to the heart. This is a priority intervention for managing dyspnea and crackles in heart failure.

B. Increase the client's intake of oral fluids: Increasing fluid intake may worsen fluid overload in clients with heart failure. These clients typically require fluid restrictions to prevent exacerbation of symptoms like pulmonary edema.

C. Instruct the client to cough every 4 hr: While coughing can help clear secretions, the symptoms in this scenario are related to fluid overload, not mucus accumulation. Coughing alone will not relieve the pulmonary congestion seen in heart failure.

D. Encourage the client to ambulate to loosen secretions: Ambulation has benefits but is not the first action when the client is short of breath and showing signs of pulmonary congestion. Activity should be limited until respiratory status stabilizes.

A. Milk B. Whole wheat bread C. Red meat D. Almonds

Correct Answer is C

Explanation

Rationale:

A. Milk: Milk does not interfere with fecal occult blood testing and does not contain substances that cause false-positive results. It can be safely consumed prior to the test without affecting the accuracy of the results.

B. Whole wheat bread: Whole wheat bread is high in fiber, which is actually beneficial when preparing for a fecal occult blood test. It helps promote regular bowel movements but does not lead to false-positive results.

C. Red meat: Red meat contains heme, a form of animal blood, which can cause false-positive results on guaiac-based fecal occult blood tests. Avoiding red meat for at least 3 days prior to the test helps reduce the risk of inaccurate results.

D. Almonds: Almonds and other nuts do not contain components that interfere with fecal occult blood testing. They are not known to cause false-positive or false-negative results and are safe to consume before the test.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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