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A nurse is assisting in the care of a group of clients who are postpartum. Which of the following clients should the nurse plan to see first?

A client who has a firm fundus following a vaginal birth and reports continuous perineal pain of 8 on a scale of 0 to 10

A client who is 30 hr postpartum and reports feeling tearful and overwhelmed

A client who is 12 hr postpartum and reports having to urinate frequently

A client who had a cesarean birth yesterday and reports burning incision pain of 5 on a scale of 0 to 10

Answer and Explanation

The Correct Answer is A

Rationale:

A. A client who has a firm fundus following a vaginal birth and reports continuous perineal pain of 8 on a scale of 0 to 10: Although the fundus is firm, severe continuous perineal pain may indicate complications such as hematoma or infection, requiring immediate assessment and intervention to prevent worsening condition.

B. A client who is 30 hr postpartum and reports feeling tearful and overwhelmed: Postpartum emotional lability is common in this timeframe and generally not an immediate safety concern. The nurse should provide support but this client’s condition is not urgent.

C. A client who is 12 hr postpartum and reports having to urinate frequently: Frequent urination postpartum may be due to diuresis or normal bladder function return and is not typically urgent unless accompanied by other signs of infection or retention.

D. A client who had a cesarean birth yesterday and reports burning incision pain of 5 on a scale of 0 to 10: Moderate incision pain is expected after surgery and can be managed with analgesics; it does not require immediate intervention compared to potential perineal complications.

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Correct Answer is C

Explanation

Rationale:

A. Prescribed epoetin V: Epoetin is used to stimulate red blood cell production, typically for anemia related to chronic kidney disease or chemotherapy. It is not a standard treatment for pernicious anemia and does not directly increase the client’s injury risk in this context.

B. Sleeps 8 to 10 hr per night: Sleeping 8 to 10 hours is within the normal range for many adults, particularly those recovering from fatigue associated with anemia. This finding does not pose any additional risk for injury.

C. Uses a firm-bristled toothbrush: A firm-bristled toothbrush can cause gum irritation or bleeding, especially in clients with anemia who may have fragile oral mucosa or concurrent thrombocytopenia. This increases the risk of oral injury or infection and should be avoided.

D. Prescribed vitamin B IM: Vitamin B12 IM injections are the standard treatment for pernicious anemia due to impaired intrinsic factor and poor absorption. This intervention helps correct the deficiency and prevent neurologic complications, not increase injury risk.

A. Direct questions to the interpreter. B. Ask the client for regular feedback. C. Incorporate acronyms into client teaching D. Ask the client's family member to interpret.

Correct Answer is B

Explanation

Rationale:

A. Direct questions to the interpreter: Communication should be directed to the client, not the interpreter. Speaking directly to the client fosters rapport and respects their autonomy, while the interpreter facilitates understanding.

B. Ask the client for regular feedback: Checking in frequently with the client ensures they understand the information being conveyed. This helps clarify misunderstandings and confirms effective communication through the interpreter.

C. Incorporate acronyms into client teaching: Using acronyms can confuse clients, especially those with limited English proficiency or unfamiliarity with medical terminology. Clear, simple language without jargon is preferred.

D. Ask the client's family member to interpret: Family members may lack medical terminology knowledge, may filter information, or breach confidentiality. Professional interpreters provide more accurate and unbiased communication.

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A nurse is assisting in the care of a group of clients who are postpartum. Which of the following clients should the nurse plan to see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has pernicious anemia. The nurse should identify that which of the following findings increases the client's risk for injury?

Correct Answer is C

Explanation

A nurse is assisting with the care of a client who needs an interpreter. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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