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Exhibits

Based on the assessment data, the nurse recognizes the need to intervene immediately.

Select the 5 priority interventions that the nurse should initiate based on the most recent assessment.

Notify primary healthcare provider

Count saturated pads per hour

Administer 2 units of packed red blood cells (PRBC)

Administer 0.2 mg methylergonovine IM

Insert straight catheter

Alert the emergency response team

Increase the IV fluid to maximum rate

Weigh all bloody materials

Massage fundus until firm

Answer and Explanation

Correct Answer : A,B,D,F,G,I

A.Notify primary healthcare provider
The client's vital signs indicate signs of potential hypovolemic shock (low blood pressure, tachycardia, fever), and the saturated pad and sheets suggest ongoing significant bleeding. Notifying the primary healthcare provider is crucial to obtain further orders and potentially escalate care.
B.   Count saturated pads per hour
Counting saturated pads per hour provides a quantitative assessment of blood loss and helps monitor the effectiveness of interventions aimed at reducing bleeding. This ongoing assessment guides further management decisions.
C.   Administer 2 units of packed red blood cells (PRBC)

While blood loss is significant, initiating a blood transfusion is not typically an immediate first-line intervention unless the client shows signs of severe hemorrhagic shock or ongoing bleeding that cannot be controlled by other measures.
D.   Administer 0.2 mg methylergonovine IM
Methylergonovine is a medication used to promote uterine contraction and control postpartum hemorrhage. Given the boggy fundus and significant bleeding, administering methylergonovine IM helps to contract the uterus and reduce bleeding.
E.   Insert straight catheter
While maintaining accurate fluid balance is important, inserting a straight catheter is not an immediate priority compared to addressing active hemorrhage and stabilizing the client's condition.
F.   Alert the emergency response team
The client's condition, with a boggy fundus, saturated pads, and ongoing bleeding, indicates a need for urgent intervention beyond routine measures. Alerting the emergency response team ensures prompt assistance and resources for managing potential hemorrhagic shock.
G.   Increase the IV fluid to maximum rate
Increasing IV fluid administration helps to restore circulating volume and stabilize the client's blood pressure. This is essential in managing hypovolemia resulting from significant postpartum hemorrhage.
H.   Weigh all bloody materials
Weighing all bloody materials is a method to estimate blood loss but is not as urgent as direct interventions aimed at stopping bleeding and stabilizing the client.
I.   Massage fundus until firm
Massaging the fundus helps to stimulate uterine contractions, which can help control bleeding by compressing blood vessels at the placental site. A boggy fundus indicates poor uterine tone, and firming it up is crucial to prevent further hemorrhage.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Rationale

A. An elevated neutrophil count suggests an active immune response to infection, supporting the clinical findings of purulent drainage. This information is crucial for the healthcare provider to assess the severity of the infection and guide treatment.

B. Hematocrit changes are more related to blood volume, fluid shifts, or bleeding rather than infection. While it may be monitored postoperatively, it does not provide specific information about infection.

C. Platelet count is important for assessing clotting function but does not directly indicate infection or purulent drainage.

D. Serum sodium levels are part of electrolyte balance and hydration status monitoring but do not directly relate to the presence of infection.

A. Increase rate of ventilation. B. Decrease expiratory flow time. C. Increase ventilator tidal volume. D. Decrease expiratory pressure.

Correct Answer is A

Explanation

Rationale

A. The client's pH is low (acidotic), and the PaCO2 is high (respiratory acidosis). Increasing the rate of ventilation (respiratory rate) can help to decrease PaCO2 by increasing alveolar ventilation, thereby helping to correct respiratory acidosis.

B. Expiratory flow time affects the time available for exhalation. While this may affect the overall mechanics of ventilation, it is not directly targeting the primary issue of elevated PaCO2 and acidosis.

C. Increasing tidal volume increases the volume of air delivered with each breath. This can improve ventilation efficiency but may not address the underlying problem of elevated PaCO2 unless it leads to increased minute ventilation.

D. Expiratory pressure is related to positive end-expiratory pressure (PEEP), which helps maintain alveolar recruitment and improve oxygenation. Decreasing expiratory pressure may not directly address the elevated PaCO2 and acidosis.

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Exhibits Based on the assessment data, the nurse recognizes the need to intervene immediately. Select the 5 priority interventions that the nurse should initiate based on the most recent assessment.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

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Exhibits

Based on the assessment data, the nurse recognizes the need to intervene immediately.

Select the 5 priority interventions that the nurse should initiate based on the most recent assessment.