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A nurse is caring for the client.

Exhibits

Nurses' Notes

Postpartum Day 3, 0815:

Client reports feeling unwell. Lung sounds clear but diminished in the bases. Client states breasts feel firm, heavy, and warm with moderate nipple discomfort while breastfeeding. Uterus firm at 1 cm above the umbilicus and tender to palpation. Fundus boggy but firmed with massage. Moderate amount of dark brown, foul-smelling lochia noted. Surgical incision well approximated with slight edema present; no signs of infection noted. No bowel movement since birth, hypoactive bowel sounds

Vital Signs

Postpartum Day 3, 0815:

Temperature 38.2° C (100.8° F)

Heart rate 104/min

Respiratory rate 18/min

BP 108/70 mm Hg

SaO2 97% on room air

Diagnostic Results

Postpartum Day 3, 0900:

Hemoglobin 11.1 g/dL

WBC count 33,000/mm3

Uterus firm at 1 cm above the umbilicus and tender to palpation.

Moderate amount of dark brown, foul-smelling lochia noted

Surgical incision well approximated with slight edema present

Temperature 38.2° C (100.8° F)

Respiratory rate 18/min

SaO2 97% on room air

WBC count 33,000/mm3

Answer and Explanation

The Correct Answer is ["A","B","D","G"]

Rationale for Correct Answers:

Uterus firm at 1 cm above the umbilicus and tender to palpation: Normally, by postpartum day 3, the uterus should be well below the umbilicus. A uterus that is still above and tender suggests endometritis or subinvolution, especially when combined with foul-smelling lochia.
Moderate amount of dark brown, foul-smelling lochia noted: Lochia should progress from rubra (day 1–3, red) → serosa (day 4–10, pink/brown) → alba (day 10 onward, white/yellow). Foul-smelling lochia is a hallmark of uterine infection (endometritis).
Temperature 38.2° C (100.8° F): A postpartum fever ≥38°C on two occasions, or even once when associated with uterine tenderness and foul lochia, is significant and indicates infection.
WBC count 33,000/mm³: Although WBCs can be physiologically elevated postpartum (up to 20,000–25,000), a count this high is abnormal and strongly suggests severe infection.

Rationale for Incorrect Answers:

Surgical incision well approximated with slight edema present: Mild edema is expected in the early healing process; no erythema, drainage, or dehiscence is noted, so no immediate concern.
Respiratory rate 18/min: This is within normal range (12–20/min), no evidence of respiratory compromise.

SaO₂ 97% on room air: This is normal oxygen saturation, not concerning

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. "I cannot be a witness for your consent to donate.": While a nurse often cannot witness the consent form to avoid a conflict of interest, this response does not directly address the client’s need for information about how to become an organ donor.

B. "Your name cannot be removed once you are listed on the organ donor list.": Clients can change their decision about organ donation at any time, and their name can be removed from the registry if they choose.

C. "Your desire to be an organ donor must be documented in writing.": Documenting consent in writing ensures legal clarity and verifies the client’s intent. Written consent is required to formalize organ donation in the medical record or donor registry.

D. "You must be at least 21 years of age to become an organ donor.": Age requirements for organ donation vary by jurisdiction, and many states allow individuals younger than 21 to register as donors, often with parental consent if under 18.

A. ABG results B. Amylase results C. Temperature D. Hematocrit level E. Pain report F. Glucose level

Correct Answer is ["A","B","C","E"]

Explanation

A. ABG results: pH 7.32 (acidosis), HCO₃⁻ 18 mEq/L (low), PaO₂ 68 mm Hg, SaO₂ 90%. Indicates metabolic acidosis with hypoxemia. This is a significant abnormality needing prompt attention.

B. Amylase results: Elevated amylase is a hallmark of acute pancreatitis and confirms the suspected diagnosis.

C. Temperature: Fever with pancreatitis can signal systemic inflammatory response or infection, requires provider notification.

D. Hematocrit level: 42%, within the normal range (female 38–47%, male 42–52%).

E. Pain report: Severe abdominal pain 8/10, persistent >24 hours. Pancreatitis pain requires provider management (often opioids, supportive care).

F. Glucose level: 108 mg/dL is within normal limits (70–110). It is not concerning at this time.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse in an emergency department is caring for a client. Exhibits Select the 4 findings the nurse should report to the provider.

Correct Answer is ["A","B","C","E"]

Explanation

A nurse is administering a scheduled medication to a client. The client reports that the medication appears different than what they take at home. Which of the following responses should the nurse make?

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A nurse is performing wound care for a client who has an abdominal incision. Which of the following techniques should the nurse implement?

A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy to obtain a copy of the therapist's notes. Which of the following responses should the nurse make?

A nurse is teaching a group of newly licensed nurses about caring for a client who has a Clostridium difficile infection. Which of the following Instructions should the nurse include in the teaching?

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