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,A,B,C

Explanation

D. Transport the client to another area of the nursing unit. The first priority is rescue ensuring the client’s safety by removing them from the immediate area of danger, which is consistent with the "RACE" fire safety protocol (Rescue, Alarm, Contain, Extinguish).

A. Activate the facility's fire alarm system. Once the client is safe, the next step is to activate the fire alarm to notify other staff and initiate emergency protocols throughout the facility.

B. Close all nearby windows and doors. Containing the fire by closing doors and windows limits the spread of smoke and flames, buying time for response teams to arrive and control the situation.

C. Use the unit's fire extinguisher to attempt to put out the fire. If it is safe and the fire is small and manageable, the final step is to extinguish the fire using a fire extinguisher, following appropriate safety procedures.

A. Urinary output 120 mL/4 hr B. Pupil diameter 6 mm C. Bowel movement 5 days ago D. Blood pressure 80/40 mm Hg

Correct Answer is D

Explanation

A. Urinary output 120 mL/4 hr. This is on the lower end of normal but not critical. It should be monitored, especially in clients on opioids, but does not require immediate reporting ahead of more life-threatening findings.
B. Pupil diameter 6 mm. Dilated pupils may suggest other issues such as anxiety, medication effects, or pain, but are not a common concern with morphine, which usually causes miosis (pupil constriction). Still, this is not the most urgent concern.
C. Bowel movement 5 days ago. Constipation is a common side effect of opioids, including morphine, and should be addressed with stool softeners or laxatives. However, it is not an emergency.
D. Blood pressure 80/40 mm Hg. This indicates hypotension, a potentially life-threatening side effect of IV morphine, especially if it results in decreased perfusion or shock. It requires immediate intervention and provider notification.

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

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

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.