A nurse is receiving report about assigned clients at the start of his shift.
Which of the following clients should the nurse plan to attend to first?
A client who is scheduled for discharge in 2 hr following a laparoscopic tubal ligation.
A client who experienced a cesarean birth 4 hr ago and reports pain.
A client who has preeclampsia and a BP of 138/90 mm Hg.
A client who experienced a vaginal birth 24 hr ago and reports no bleeding.
The Correct Answer is B
Choice A rationale:
The nurse should prioritize the client's needs based on the severity of their condition. A client scheduled for discharge in 2 hours following a laparoscopic tubal ligation is generally stable and not in immediate need of care. Discharge planning can be done later.
Choice B rationale:
A client who experienced a cesarean birth 4 hours ago and reports pain requires immediate attention. Pain is a subjective symptom that should be addressed promptly to ensure the client's comfort and well-being. Uncontrolled pain can lead to complications and negatively affect the client's overall recovery.
Choice C rationale:
A client with preeclampsia and a blood pressure of 138/90 mm Hg is a concerning situation, but it is not the top priority in this scenario. Preeclampsia requires monitoring and intervention, but the client who just had a cesarean birth and is experiencing pain should be attended to first.
Choice D rationale:
A client who experienced a vaginal birth 24 hours ago and reports no bleeding is not a high-priority concern. Some clients may have minimal bleeding or none at all after a vaginal birth, and this can be normal. The absence of bleeding alone does not warrant immediate attention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: Decreased energy is a common symptom during pregnancy, especially in the first and third trimesters. This is typically due to hormonal changes, increased demands on the body, and changes in sleep patterns. While decreased energy can be uncomfortable, it is usually not a sign of a serious problem and does not require immediate medical attention unless it is severe or accompanied by other concerning symptoms.
Choice B rationale: Urinary frequency is another common symptom during pregnancy, caused by hormonal changes and the growing uterus putting pressure on the bladder. This symptom is usually most noticeable in the first and third trimesters. While it can be inconvenient, it is generally not a cause for concern and does not require a call to the healthcare provider unless it is accompanied by pain or other symptoms suggestive of a urinary tract infection.
Choice C rationale: Mood swings are a frequent occurrence during pregnancy due to hormonal fluctuations. Pregnant individuals may experience a wide range of emotions, from happiness and excitement to anxiety and irritability. While mood swings can be challenging to manage, they are typically not a sign of a serious problem and do not necessitate immediate medical attention unless they are severe and impact daily functioning.
Choice D rationale: Facial edema, or swelling of the face, can be a sign of preeclampsia, a serious condition that can occur during pregnancy. Preeclampsia is characterized by high blood pressure and can lead to complications for both the mother and baby if left untreated. Other signs of preeclampsia can include severe headaches, visual disturbances, and rapid weight gain. If a pregnant individual experiences facial edema, it is important to contact their healthcare provider promptly for evaluation and management.
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale:
Blotting the perineal area dry after voiding is an important part of perineal care. Moisture can contribute to perineal infection, so it is essential to keep the area dry. This practice helps prevent the growth of bacteria and reduces the risk of infection.
Choice D rationale:
Cleaning the perineal area from front to back is crucial in reducing the risk of perineal infection. This method helps prevent the transfer of bacteria from the anal area to the perineum and vaginal area, reducing the risk of infection.
Choice E rationale:
Performing hand hygiene before and after voiding is an important aspect of perineal care and infection prevention. Proper hand hygiene helps prevent the transfer of bacteria from the hands to the perineal area and vice versa, reducing the risk of infection.
Choice B rationale:
Applying ice packs to the perineal area several times daily is not a recommended practice for reducing the risk of perineal infection. While ice packs can provide pain relief and reduce swelling, they should not be applied excessively, as prolonged exposure to cold can compromise blood flow and potentially increase the risk of tissue damage or infection.
Choice C rationale:
Sitting on an inflatable donut to protect the perineum is not a recommended practice for reducing the risk of perineal infection. Inflatable donuts can increase pressure on the perineal area, potentially causing discomfort and impairing blood flow. Proper hygiene and keeping the area clean and dry are more effective strategies for infection prevention. .
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