A nurse is caring for the client.

Exhibits

Select the 5 findings that indicate the client's condition has improved.

Heart rate

Temperature

Lochia

Hgb

WBC count

Fundal height

Answer and Explanation

Correct Answer : A,B,C,E,F

A. Heart rate. The client’s heart rate decreased from 110/min on postpartum day 3 to 78/min on day 5, returning to normal resting range, which suggests improvement in systemic inflammation or infection, and better overall hemodynamic stability.
B. Temperature. The temperature has decreased from 38.6° C (101.5° F) to 37.1° C (98.9° F), which is within normal limits. This reduction is a key indicator of resolving infection or inflammation, especially considering the earlier febrile response.
C. Lochia. Lochia has improved from a moderate, foul-smelling, dark brown discharge to a small amount of brownish-red lochia with no odor, which suggests infection resolution and appropriate progression of postpartum uterine involution.
D. Hgb. The client’s hemoglobin dropped from 11.1 g/dL to 10 g/dL, which is below the normal postpartum range. This is likely due to ongoing recovery, recent surgery, and fluid shifts, but it does not indicate improvement and may require continued monitoring.
E. WBC count. The WBC count normalized from a significantly elevated 33,000/mm³ to 10,000/mm³, which is within the normal reference range. This is a strong sign that the infection or inflammatory response is resolving.
F. Fundal height. The fundus has decreased from 1 cm above the umbilicus on day 3 to 4 cm below on day 5, which is consistent with normal involution of the uterus during the postpartum period and is a positive sign of recovery.

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Correct Answer is D

Explanation

A. Abdominal aortic aneurysm. While an abdominal aortic aneurysm is a serious vascular condition, it is not directly affected by localized heat therapy to an extremity such as the foot. However, heat should still be used cautiously near major vascular abnormalities.
B. Phlebitis. Heat therapy is often used to reduce inflammation and promote circulation in conditions like phlebitis. Although care must be taken, it is not an absolute contraindication and may actually be prescribed in some mild cases under supervision.
C. Osteoarthritis. Heat therapy is commonly used for osteoarthritis to relax muscles, improve joint mobility, and alleviate stiffness and discomfort. It is considered a beneficial and appropriate treatment modality for this condition.
D. Peripheral neuropathy. Clients with peripheral neuropathy may have impaired sensation, making them unable to detect excessive heat. This puts them at high risk for burns or thermal injury, making heat therapy a contraindication for safety reasons.

A. Draw up regular insulin prior to NPH insulin. B. Roll the syringe gently to ensure mixture of the insulins. C. Inject into the vastus lateralis. D. Use a 15 angle for the injection

Correct Answer is A

Explanation

A. Draw up regular insulin prior to NPH insulin. This is the correct technique when mixing short-acting (regular) and intermediate-acting (NPH) insulins in the same syringe. Drawing up regular insulin first prevents contamination of the clear insulin vial with the cloudy NPH, which could alter the action of the regular insulin.
B. Roll the syringe gently to ensure mixture of the insulins. Insulin should be mixed in the vial before drawing it into the syringe—not after. NPH insulin should be gently rolled between the hands to mix it, but the syringe itself should not be rolled after drawing both insulins, as this can introduce bubbles and affect dosing accuracy.
C. Inject into the vastus lateralis. The preferred sites for subcutaneous insulin administration are areas with sufficient subcutaneous tissue, such as the abdomen, upper outer arms, thighs, or buttocks. The vastus lateralis is more commonly used for intramuscular injections, such as vaccines.
D. Use a 15° angle for the injection. A 15° angle is appropriate for intradermal injections, not subcutaneous insulin injections. For insulin, the correct angle is typically 45° or 90°, depending on the client’s body habitus and needle length, to ensure proper subcutaneous delivery.

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A nurse is caring for the client. Exhibits Select the 5 findings that indicate the client's condition has improved.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a client who has a prescription for intermittent heat therapy for a foot injury. Which of the following findings should the nurse identify as a contraindication for heat therapy?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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A nurse is caring for the client.

Exhibits

Select the 5 findings that indicate the client's condition has improved.