A nurse is providing care for a group of postpartum clients. Which of the following clients should the nurse see first?

A client who is 4 hr postpartum and has a heart rate of 90/min

A client who is 4 days postpartum and has a WBC count of 18,000/mm3 (5,000 to 10,000/mm3)

A client who is 12 hr postpartum and has an oral temperature of 37.8° C (100° F)

A client who is 2 days postpartum and reports dysuria

Answer and Explanation

The Correct Answer is B

Rationale:

A. A client who is 4 hr postpartum and has a heart rate of 90/min: A heart rate of 90/min is within normal postpartum limits. This client is stable and does not require immediate assessment, making them a lower priority compared to clients showing signs of possible infection or complications.

B. A client who is 4 days postpartum and has a WBC count of 18,000/mm³ (5,000 to 10,000/mm³): An elevated WBC count 4 days postpartum can indicate a serious infection, such as endometritis or another postpartum infection. This client is at risk for rapid deterioration and requires immediate assessment and intervention.

C. A client who is 12 hr postpartum and has an oral temperature of 37.8° C (100° F): A mild temperature elevation shortly after birth can be expected due to normal postpartum physiologic changes. While it should be monitored, it is not as urgent as the markedly elevated WBC count indicating potential infection.

D. A client who is 2 days postpartum and reports dysuria: Dysuria may indicate a urinary tract infection, which requires evaluation, but this is less immediately threatening than a client with signs of systemic infection. This client should be assessed after clients with potential severe infection or hemodynamic instability.

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Correct Answer is D

Explanation

Rationale:

A. Instruct the client that this is due to increased salivary flow that occurs with aging: While aging can affect swallowing, persistent coughing specifically during meals suggests dysphagia or aspiration risk, not just increased saliva. Dismissing it as normal aging could delay necessary evaluation and intervention.

B. Encourage the client to increase fluid intake when the cough is present: Increasing fluids without assessing swallowing ability could worsen aspiration risk. Proper evaluation of swallowing mechanics is necessary before recommending fluid intake adjustments.

C. Recommend an antitussive 30 min prior to each meal: Suppressing the cough reflex can be dangerous in clients with swallowing difficulties, as the cough helps prevent aspiration. Using antitussives in this situation may increase the risk of choking or pneumonia.

D. Initiate a consultation with a speech-language pathologist: A speech-language pathologist can perform a swallowing assessment, identify aspiration risk, and recommend safe feeding strategies. Referral ensures proper evaluation and helps prevent complications such as aspiration pneumonia.

A. Stay with the client for the first 15 min of the transfusion. B. Obtain the first unit of packed RBCs from the blood bank. C. Document the blood product transfusion in the client's medical record. D. Start an IV bolus of lactated Ringers solution. E. Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg 4

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

Explanation

Rationale:

• Stay with the client for the first 15 min of the transfusion: The first 15 minutes of a blood transfusion are critical for monitoring signs of a transfusion reaction, such as fever, chills, rash, or hypotension. Continuous observation allows the nurse to promptly intervene and prevent complications.

• Obtain the first unit of packed RBCs from the blood bank: Retrieving the blood from the blood bank ensures that the correct product is available for transfusion and meets safety protocols. Verification of type and crossmatch is essential before administration.

• Document the blood product transfusion in the client's medical record: Accurate documentation of the transfusion, including product type, volume, time, and client response, is required for legal, medical, and safety purposes. It ensures continuity of care and provides a record for any adverse events.

• Start an IV bolus of lactated Ringers solution: Routine IV bolus of lactated Ringer’s is not indicated unless the client has persistent hypotension requiring fluid resuscitation. Blood transfusion itself is the primary intervention to correct anemia in this client.

• Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg: While monitoring blood pressure is important, adjusting the transfusion rate specifically to maintain a numeric BP is not standard practice. The transfusion rate should follow protocol, usually starting slow for the first 15 minutes and then adjusted per tolerance, not solely based on BP.

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A nurse is providing care for a group of postpartum clients. Which of the following clients should the nurse see first?

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Naxlex Comprehensive Predictor Exams

A home health nurse is caring for an older adult client who reports. "I keep coughing when I try to swallow my food, but not at other times." Which of the following actions should the nurse take?

Correct Answer is D

Explanation

The nurse reviews the entries in the medical record Exhibits The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client.

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

Explanation

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