A nurse is caring for a client who is 1 hr postpartum and unable to urinate.
Which of the following actions should the nurse take?

Place the client's hands in warm water.

Perform a fundal massage.

Administer a benzodiazepine.

Place an ice pack on the client's perineum.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Placing the client's hands in warm water is a method to stimulate urination and is appropriate for clients experiencing difficulty voiding.

Choice B rationale:

Performing a fundal massage is incorrect choice in this scenario.

Choice C rationale:

Administering a benzodiazepine is not appropriate for this situation. Benzodiazepines are a class of medications primarily used for anxiety, insomnia, and seizures. There is no indication for the use of benzodiazepines in this case, as the client's inability to urinate is likely related to a physiological issue postpartum, not anxiety or seizures.

Choice D rationale:

Placing an ice pack on the client's perineum is not the correct intervention for this situation. Ice packs on the perineum are typically used to reduce swelling and relieve pain after childbirth. However, the client's inability to urinate suggests a potential issue within the urinary system, and a fundal massage to promote uterine contractions would be more appropriate.

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Correct Answer is A

Explanation

Choice A rationale:

Glargine insulin is a long-acting insulin that provides a basal level of insulin over 24 hours. It is suitable for managing blood glucose levels in clients with diabetes mellitus who require a long-acting insulin to maintain glycemic control throughout the day.

Choice B rationale:

NPH insulin is an intermediate-acting insulin that lasts for about 12-16 hours. While it can be used for blood glucose management, it is not the best choice for a client needing long-acting insulin coverage throughout the day.

Choice C rationale:

Insulin aspart is a rapid-acting insulin used to control postprandial glucose levels. It acts quickly to lower blood sugar after meals and is not suitable for long-acting coverage.

Choice D rationale:

Regular insulin, also known as short-acting insulin, is used to control blood glucose levels during meals. It has a faster onset of action compared to long-acting insulins and is not appropriate for managing basal insulin needs over an entire day.

A. Keep an abduction pillow between the client's legs. B. Elevate the client's affected leg on a pillow when in bed. C. Position the client's knees slightly higher than the hips when up in a chair. D. Raise the head of the client's bed to a high-Fowler's position.

Correct Answer is A

Explanation

Choice A rationale:

Keeping an abduction pillow between the client's legs is a preventive measure to avoid dislocation of the hip prosthesis. This positioning helps maintain the correct alignment of the hip joint, reducing the risk of dislocation. Abduction pillows are commonly used postoperatively after total hip arthroplasty to support proper hip positioning while the patient is in bed.

Choice B rationale:

Elevating the client's affected leg on a pillow when in bed is not recommended after total hip arthroplasty. This position could lead to hip adduction, increasing the risk of prosthesis dislocation. Maintaining abduction (spreading the legs apart) is the key to preventing dislocation, and elevation should be avoided to maintain proper alignment.

Choice C rationale:

Positioning the client's knees slightly higher than the hips when up in a chair is not an appropriate preventive measure for prosthesis dislocation. Proper alignment is crucial, and the client should avoid sitting in low chairs or on low surfaces that could cause the hips to be lower than the knees, potentially leading to dislocation.

Choice D rationale:

Raising the head of the client's bed to a high-Fowler's position is unrelated to preventing prosthesis dislocation. Fowler's position refers to elevating the head of the bed to assist with breathing and facilitate patient comfort. While this position might be suitable for certain respiratory conditions, it has no direct impact on the stability of a hip prosthesis.

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A nurse is caring for a client who is 1 hr postpartum and unable to urinate. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has diabetes mellitus and is receiving long-acting daily insulin for blood glucose management.The nurse should anticipate administering which of the following types of insulin?

Correct Answer is A

Explanation

A nurse is caring for a client who is postoperative following total hip arthroplasty.Which of the following actions should the nurse take to prevent dislocation of the prosthesis?

Correct Answer is A

Explanation

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A nurse is caring for a client who is 1 hr postpartum and unable to urinate.
Which of the following actions should the nurse take?