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A nurse reviews the provider prescriptions and reassesses the client.

Exhibits
The nurse is continuing to care for the client. Which of the following actions should the nurse take? Select all that apply.

Inform the client she will need to formula feed her newbom until she has received antibiotics for 24 hr.

Request a prescription for terbutaline from the provider.

Monitor the height and tone of the client's fundus.

Instruct the client to wash her hands before and after changing her perineal pad.

Encourage the client to maintain a semi-Fowler's position to enhance uterine drainage.

Obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab.

Initiate contact precautions.

Answer and Explanation

Correct Answer : C,D,E,F

Rationale:

A. Inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr: Most antibiotics used to treat postpartum endometritis are safe for breastfeeding. Temporary formula feeding is not routinely required.

B. Request a prescription for terbutaline from the provider: Terbutaline is a tocolytic used to suppress preterm labor, which is not indicated postpartum. It does not treat infection or uterine complications.

C. Monitor the height and tone of the client's fundus: Assessing the uterus for firmness and position helps detect uterine atony or worsening infection. Changes in fundal height or tone can indicate retained products of conception or hemorrhage.

D. Instruct the client to wash her hands before and after changing her perineal pad: Hand hygiene reduces the risk of introducing or spreading bacteria to the uterus or perineal area, which is critical when postpartum infection is present.

E. Encourage the client to maintain a semi-Fowler's position to enhance uterine drainage: Semi-Fowler’s positioning promotes drainage of lochia, decreases uterine congestion, and supports recovery from endometritis by reducing bacterial proliferation in pooled fluid.

F. Obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab: A culture helps identify the causative organism of endometritis, allowing the provider to tailor antibiotic therapy effectively.

G. Initiate contact precautions: Endometritis is not a highly transmissible condition; standard precautions, including hand hygiene, are sufficient unless another communicable infection is identified.

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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. Provide the client with high-calorie fluids every hour. B. Encourage the client to avoid napping during the day. C. Minimize environmental stimuli for the client. D. Weigh the client each day.

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

Explanation

Rationale:

Provide the client with high-calorie fluids every hour: The client has poor self-care, has not eaten for an extended period, and exhibits hyperactivity due to mania. Frequent high-calorie fluids help maintain hydration and meet increased metabolic demands. Regular intake supports nutrition and prevents further weight loss.
Encourage the client to avoid napping during the day: Avoiding daytime napping can help regulate sleep-wake cycles and promote restorative sleep at night. Clients experiencing mania often have decreased need for sleep, so reinforcing nighttime sleep routines supports stabilization of circadian rhythms.

Minimize environmental stimuli for the client: Clients experiencing a manic episode are easily overstimulated, which can worsen their agitation, anxiety, and psychosis. A calm, quiet environment with reduced distractions is essential for de-escalation and promoting rest.
Weigh the client each day: Daily weight monitoring helps assess nutritional status and detect fluid imbalance, which is important given the client’s poor self-care, hyperactivity, and potential for dehydration or rapid weight loss.

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A nurse reviews the provider prescriptions and reassesses the client. Exhibits The nurse is continuing to care for the client. Which of the following actions should the nurse take? Select all that apply.

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

The nurse continues to care for the client. Exhibits A nurse on the inpatient mental health unit is planning care for the client. For each potential provider's prescription, click to specify if the prescription is anticipated or contraindicated for the client

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

Explanation

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A nurse reviews the provider prescriptions and reassesses the client.

Exhibits
The nurse is continuing to care for the client. Which of the following actions should the nurse take? Select all that apply.