Exhibits
Click to highlight the findings that indicate improvement in the client's condition. To deselect a finding, click on the finding again.
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Assessment |
Findings |
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Nurses' Notes |
Client rates lower back pain a 0 on a scale from 0 to 10. No reports of vaginal discharge. Membranes intact No uterine contractions noted. |
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FHR baseline 138, minimal variability. No further reports of burning with urination. |
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Laboratory Results |
WBC 12,000/mm2 (5,000 to 10,000/mm3) Platelet count 188,000/mm3 (150,000 to 400,000/mm3) |
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Vital Signs |
Temperature 37.1° C (98.7° F) Blood pressure 120/78 mm Hg |
Client rates lower back pain a 0 on a scale from 0 to 10. No reports of vaginal discharge.
No uterine contractions noted.
No further reports of burning with urination.
WBC 12,000/mm2 (5,000 to 10,000/mm3)
Temperature 37.1° C (98.7° F)
Membranes intact
FHR baseline 138, minimal variability.
Platelet count 188,000/mm3 (150,000 to 400,000/mm3)
Blood pressure 120/78 mm Hg
The Correct Answer is ["A","B","C","D","E"]
Client rates lower back pain as 0 on a scale from 0 to 10:
On Day 1, the client reported lower back pain, which could be associated with uterine contractions or other complications. By Day 2, the pain has resolved completely, with the client reporting a pain level of 0/10. This is a clear sign of improvement in her condition, especially since pain is often a key indicator of progress in antepartum care.
No reports of vaginal discharge:
On Day 1, the client reported pinkish vaginal discharge, which can be indicative of preterm labor or other complications. By Day 2, the absence of vaginal discharge suggests that the situation has improved, and the risk of preterm labor may be decreasing.
No uterine contractions noted:
On Day 1, the client had uterine contractions occurring every 8 minutes, which could be indicative of early labor or preterm labor. By Day 2, the absence of uterine contractions is a positive sign that the client is no longer experiencing early labor signs. This indicates that the situation is improving.
No further reports of burning with urination:
On Day 1, the client reported burning with urination, which was indicative of a urinary tract infection (UTI). On Day 2, the client no longer reports this symptom, suggesting that the urinary symptoms have resolved, and the infection may be improving, especially in light of ongoing treatment (e.g., antibiotics).
Laboratory Results Indicating Improvement:
WBC count 12,000/mm³ (Day 2) vs. 16,000/mm³ (Day 1):
The WBC count has decreased from 16,000/mm³ on Day 1 (which indicated infection or inflammation) to 12,000/mm³ on Day 2. Although the WBC count is still slightly elevated above the normal range (5,000-10,000/mm³), the decrease in WBC count suggests that the client's body is responding to treatment, and the infection or inflammation may be resolving.
Vital Signs Indicating Improvement:
Temperature 37.1° C (98.7°F) (Day 2) vs. 38.4° C (101.1°F) (Day 1):
The client’s fever has resolved, with a temperature decrease from 38.4°C (101.1°F) on Day 1 to 37.1°C (98.7°F) on Day 2. Fever is a common sign of infection, and the reduction in temperature suggests that the infection (likely a urinary tract infection) is being controlled and is improving.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A filter needle should be used to withdraw the medication from a glass ampule to prevent glass particles from entering the syringe.
B. The neck of the ampule should be broken away from the body to avoid injury.
C. The ampule should be disposed of in a puncture-proof container, not in the trash.
D. A different needle should be used for injection after the medication is drawn up to ensure it is sterile.
Correct Answer is ["A","B","E"]
Explanation
Correct actions;
A. A large-bore IV catheter is recommended for blood transfusions because it allows for faster and more efficient administration of the blood product. Blood transfusions require proper blood flow to prevent damage to the blood cells, and a larger catheter (usually 18 or 20 gauge) ensures this. A smaller catheter may increase the risk of hemolysis (destruction of red blood cells) or slower transfusion rates, which is not ideal in an emergency situation.
B. It is mandatory to obtain informed consent before any transfusion procedure. The nurse is required to witness the client’s signature on the consent form, ensuring that the client understands the procedure, risks, and benefits. The client’s statement of concern ("I'm really scared...") emphasizes the importance of having a thorough discussion and ensuring they understand what is happening.
E. Two nurses must independently verify the blood product details (such as the blood type and matching the client’s identification) before the transfusion begins. This double-checking procedure is a safety protocol to prevent transfusion errors, such as administering the wrong blood type, which can lead to severe reactions and complications.
Incorrect actions:
C. Dextrose solutions (D5W) should not be used to flush blood transfusion tubing. This is because dextrose solutions can cause hemolysis (destruction of red blood cells) when mixed with blood. The correct solution to flush blood transfusion lines is normal saline (0.9% sodium chloride), as it is compatible with blood products and helps prevent damage to the red blood cells.
D. Transfusion reactions, although rare, can be serious and even life-threatening. It is important for the nurse to provide accurate and clear information about potential transfusion reactions (e.g., allergic reactions, fever, hemolytic reactions, anaphylaxis) and to educate the client on what to expect
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