A woman who delivered a normal newborn 24 hours ago reports, "I seem to be urinating every hour or so. Is that OK?”. Which action should the practical nurse (PN) implement?
Catheterize the client for residual urine volume.
Evaluate for normal involution, then massage the fundus.
Measure the next voiding, then palpate the client's bladder.
Obtain a specimen for urine culture and sensitivity.
The Correct Answer is C
Correct Answer: C. Measure the next voiding, then palpate the client's bladder.
Choice A rationale:
Catheterizing the client for residual urine volume is not necessary at this point because the woman has recently given birth, and frequent urination is common during the postpartum period. Additionally, catheterization poses risks of infection, so it should be reserved for situations where it is clinically indicated.
Choice B rationale:
Evaluating for normal involution and massaging the fundus is not relevant in this context. Fundal massage is performed after childbirth to ensure the uterus contracts and prevents excessive bleeding. The woman's concern is about frequent urination, which does not require fundal massage.
Choice C rationale:
Measuring the next voiding and palpating the client's bladder is the most appropriate action. The woman's increased frequency of urination could be due to postpartum diuresis, a normal physiological process where the body eliminates excess fluid accumulated during pregnancy. By measuring the next voiding and palpating the bladder, the nurse can assess for bladder distension or retention, which could be signs of a problem.
Choice D rationale:
Obtaining a specimen for urine culture and sensitivity is not indicated in this situation. There is no evidence to suggest that the woman has a urinary tract infection or other urinary issues that would warrant a urine culture at this time.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice d. Powerful craving for more.
Rationale:
Cocaine withdrawal symptoms are primarily psychological and emotional, rather than physical. While some physical symptoms may occur, such as fatigue and muscle aches, the most prominent and concerning aspects of withdrawal are intense cravings for the drug.
Here's a breakdown of the other choices and why they are not as likely:
- Choice a. Elevated energy level:Cocaine is a stimulant,so during withdrawal,a person is more likely to experiencedecreased energy and fatigue.
- Choice b. High self-esteem:Cocaine use can initially boost self-esteem,but withdrawal often leads to feelings ofdepression, anxiety, and worthlessness.
- Choice c. Euphoria:Euphoria is one of the main effects of cocaine use,but during withdrawal,the opposite occurs,with individuals experiencingdysphoria, a state of intense negative emotions.
Therefore, the intense craving for more cocaine is the most characteristic behavioral symptom exhibited during cocaine withdrawal. This craving is driven by the brain's adaptation to the drug's presence and the disruption of dopamine and other neurotransmitter systems caused by withdrawal.
Additional Notes:
- The intensity of cocaine withdrawal symptoms can vary depending on several factors,including the severity and duration of cocaine use,individual differences in brain chemistry and genetics,and the presence of co-occurring mental health conditions.
- Seeking professional help for cocaine withdrawal is crucial to manage cravings and other symptoms effectively and increase the chances of successful recovery.
Correct Answer is A
Explanation
The correct answer is choice A: Never scratch under the cast.
Choice A rationale:
It is important not to scratch under the cast because inserting objects can lead to skin injury and infection. If itching occurs, blowing cool air from a hair dryer into the cast is recommended.
Choice B rationale:
While mild swelling and some discomfort are common after a cast is applied, patients should not expect an increase in pain. Persistent or severe pain could indicate complications such as increased swelling, decreased blood flow, or pressure on nerves and should be evaluated by a healthcare provider.
Choice C rationale:
Applying a cold pack to “hot spots” on the cast is not recommended as it can lead to moisture accumulation and skin problems. Instead, to manage swelling and discomfort, ice can be applied over the cast, covered with a thin towel, for 20 minutes every two hours while awake during the first 48 hours.
Choice D rationale:
Keeping the injured leg in a dependent position is not advised because it can increase swelling and pain. The affected limb should be elevated above the level of the heart to reduce swelling and promote healing.
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