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. Heparin 5000 U subcutaneous every 8 hr: Using "U" for units can be misread as zero, potentially causing a tenfold overdose. The correct transcription uses the full word "units" to prevent errors.
B. M50, 10g PO delly: This prescription contains multiple errors: "M50" is unclear, "10g" may be excessive or incorrect dosing, and "delly" is an incorrect abbreviation for daily. This transcription is inaccurate and unsafe.
C. Lorazepam 0.5 mg PO PRN at bedtime: Although mostly correct, "PRN at bedtime" can be confusing. It is clearer to specify "PRN for anxiety at bedtime" or "PRN as needed at bedtime" to clarify the indication and timing.
D. Doxazosin 5 mg PO at bedtime: This transcription is clear, uses accepted abbreviations, specifies route and time, and includes no dangerous abbreviations, making it an accurate and safe prescription transcription.
Correct Answer is C
Explanation
Rationale:
A. Nystagmus: Nystagmus is characterized by involuntary eye movements and is typically associated with vestibular disorders, multiple sclerosis, or congenital conditions. It is not a symptom of macular degeneration, which primarily affects the retina.
B. Astigmatism: Astigmatism is a refractive error due to an irregularly shaped cornea or lens. It is unrelated to macular degeneration, which involves degeneration of the macula—the part of the retina responsible for sharp central vision.
C. Loss of central vision: Macular degeneration leads to progressive deterioration of the macula, resulting in blurred or complete loss of central vision while peripheral vision remains intact. This is a hallmark symptom and significantly affects activities like reading and recognizing faces.
D. Client reports sharp pain: Macular degeneration does not typically cause pain. It is a painless condition, and the presence of sharp eye pain may suggest another acute ocular issue such as glaucoma or injury, not related to macular changes.
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