A nurse is caring for the client.

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

WBC count

Heart rate

Fundal height

Temperature

Hgb

Lochia

Answer and Explanation

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

A. WBC count: The client’s WBC count decreased from 33,000/mm³ to 10,000/mm³, returning to the expected postpartum reference range. This decline indicates resolution of the infectious or inflammatory process, consistent with effective antibiotic therapy for postpartum infection such as endometritis.

B. Heart rate: The heart rate decreased from tachycardic values (104–110/min) to 78/min, which is within normal limits. Resolution of tachycardia suggests improvement in systemic stress, infection, and overall hemodynamic stability.

C. Fundal height: The fundus progressed from being above the umbilicus to 4 cm below the umbilicus, demonstrating appropriate uterine involution. This finding reflects improved uterine tone and reduced risk of postpartum hemorrhage or ongoing uterine infection.

D. Temperature: The client’s temperature normalized from febrile readings (38.2–38.6°C) to 37.1°C. Resolution of fever is a key indicator of infection control and clinical improvement following antimicrobial treatment.

E. Hgb: Hemoglobin decreased from 11.1 g/dL to 10 g/dL, which does not indicate improvement. This trend suggests ongoing physiologic postpartum blood loss or dilution and does not reflect recovery.

F. Lochia: Lochia changed from dark brown with foul odor to a small amount of brownish-red lochia without odor. This improvement indicates resolution of uterine infection and normalization of postpartum uterine discharge.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A,C"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

Rationale:

• Tachycardia: Tachycardia is a common early sign of both malignant hyperthermia and hypovolemic shock. In malignant hyperthermia, it results from excessive metabolic activity and catecholamine release. In hypovolemic shock, tachycardia is a compensatory response to decreased circulating volume to maintain perfusion.

• Hypercapnia: Elevated PaCO2 occurs in malignant hyperthermia due to increased muscle metabolism and CO2 production. Hypercapnia is a hallmark early indicator of this condition. It is not typically observed in latex allergy or hypovolemic shock.

• Urticaria: Urticaria (hives) is a classic manifestation of a latex allergy, reflecting an IgE-mediated hypersensitivity reaction. Clients may also experience pruritus or flushing. Urticaria is not characteristic of malignant hyperthermia or hypovolemic shock.

• Muscle rigidity: Muscle rigidity, especially of the jaw (masseter), is a hallmark sign of malignant hyperthermia caused by an uncontrolled release of calcium in skeletal muscles triggered by certain anesthetic agents. Rigidity does not occur with latex allergy or hypovolemic shock.

• Wheezing: Wheezing is consistent with latex allergy due to airway hypersensitivity and bronchospasm. Respiratory compromise in latex allergy can progress rapidly if untreated. Wheezing is not typically seen in malignant hyperthermia or hypovolemic shock.

A. Evaluate the client's ability to help with repositioning B. Reposition the client without the use of assistive devices. C. Discuss the client's preferences for determining a repositioning schedule. D. Raise the side rails on both sides of the client's bed during repositioning.

Correct Answer is A

Explanation

A. Evaluate the client's ability to help with repositioning: Assessing the client’s strength, motor function, and level of cooperation is essential to determine how much assistance is needed and which repositioning techniques are safest. Stroke clients may have hemiplegia or weakness, and understanding their abilities prevents injury to both the client and the nurse.

B. Reposition the client without the use of assistive devices: Using assistive devices such as slide sheets, gait belts, or mechanical lifts is recommended for clients with limited mobility to reduce the risk of musculoskeletal injury. Repositioning without them increases the likelihood of strain or falls.

C. Discuss the client's preferences for determining a repositioning schedule: While client preferences can enhance comfort and adherence, safety and prevention of complications such as pressure injuries take priority. Scheduling should follow clinical guidelines rather than preference alone.

D. Raise the side rails on both sides of the client's bed during repositioning: Raising both side rails can create a fall hazard or limit safe access for the nurse during repositioning. Typically, one side rail may be raised as needed, while the other is lowered to allow safe maneuvering.

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

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A nurse is caring for a client who is postoperative following a right hip arthroplasty. For each assessment finding, click to specify if the finding is consistent with Malignant hyperthermia, Latex allergy, or Hypovolemic shock. Each finding may support more than 1 disease process.

Correct Answer is {"A":{"answers":"A,C"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

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Correct Answer is A

Explanation

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