A straight catheter produced 500 mL of clear yellow urine.

For each finding, indicate whether the findings suggest that the client’s condition has improved or put the client at risk for hypovolemia.

Each column must have at least one selection.

Total blood loss of 800 mL

Fundus massaged until firm and at umbilicus

Multiple large clots were expelled

Blood pressure of 110/80 mm Hg, heart rate of 66 beats/minute, oxygen saturation at 98% on room air .

Answer and Explanation

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

The findings suggest that the client’s condition has improved.

Choice A rationale

A total blood loss of 800 mL is a significant amount, but it is within the normal range for blood loss during and after childbirth. Therefore, this does not necessarily put the client at risk for hypovolemia.

Choice B rationale

A fundus that is firm and at the level of the umbilicus indicates that the uterus is contracting properly after childbirth, which helps to prevent excessive bleeding.

Choice C rationale

The expulsion of multiple large clots could indicate that the body is effectively clotting blood, which can prevent excessive bleeding.

Choice D rationale

A blood pressure of 110/80 mm Hg, a heart rate of 66 beats/minute, and an oxygen saturation of 98% on room air are all within normal ranges, indicating that the client is stable and not at risk for hypovolemia.

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Correct Answer is D

Explanation

Choice A rationale

While it’s important to assess all aspects of the patient’s condition, a warm left lower extremity does not necessarily indicate a right hip fracture. It could be related to other conditions, such as deep vein thrombosis or cellulitis.

Choice B rationale

The presence of strong bilateral pedal pulses is a positive sign and does not indicate a hip fracture. It suggests that the patient has good peripheral circulation.

Choice C rationale

The ability to wiggle the toes when the sole of the right foot is tickled does not necessarily indicate a hip fracture. This is a normal response and suggests that the patient has intact sensory and motor function in the foot.

Choice D rationale

A right leg that is externally rotated and shorter than the left is a classic sign of a hip fracture. This occurs because the fracture can cause the femoral head to tilt and rotate outward, making the leg appear shorter.

A. Advise the parent to reduce the infant’s fruit intake for 24 hours. B. Recommend the parent to clean with soap and water at each diaper change. C. Instruct the parent to change the child’s diaper more frequently. D. Encourage the parent to apply lotion with each diaper change.

Correct Answer is C

Explanation

Choice A rationale

Reducing the infant’s fruit intake for 24 hours is not the best approach in this situation. While certain fruits can cause diarrhea, the parent reports no signs of watery stools. Therefore, this intervention may not address the issue of the red and raw diaper area.

Choice B rationale

Cleaning with soap and water at each diaper change can actually worsen the condition. Soap can dry out the skin and disrupt the skin’s natural barrier, potentially leading to more irritation. It’s generally recommended to use water and a soft cloth, or a gentle non-soap cleanser, to clean the diaper area.

Choice C rationale

Changing the child’s diaper more frequently is the most appropriate intervention. A wet or dirty diaper can irritate the skin, leading to diaper rash. By changing the diaper more often, the skin is kept clean and dry, which can help the rash heal.

Choice D rationale

Applying lotion with each diaper change is not typically recommended for diaper rash. Some lotions can contain fragrances or other ingredients that can further irritate the rash. Instead, a barrier cream or ointment, such as one containing zinc oxide, is often recommended.

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A straight catheter produced 500 mL of clear yellow urine. For each finding, indicate whether the findings suggest that the client’s condition has improved or put the client at risk for hypovolemia. Each column must have at least one selection.

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Naxlex Comprehensive Predictor Exams

An elderly patient who had a fall at a store is admitted with a potential right hip fracture.What assessment finding should the nurse report to the healthcare provider?

Correct Answer is D

Explanation

The parent of a 7-month-old infant visits the clinic due to the infant’s diaper area being red and raw, but without any blisters or bleeding.The parent reports no signs of watery stools.What nursing intervention should the nurse implement?

Correct Answer is C

Explanation

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A straight catheter produced 500 mL of clear yellow urine.

For each finding, indicate whether the findings suggest that the client’s condition has improved or put the client at risk for hypovolemia.

Each column must have at least one selection.