Exhibits

The nurse is reviewing the client's chart.

For each finding, click to indicate whether 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.

Fundus massaged until firm and at umbilicus

Multiple large clots were expelled

Straight catheter produced 500 mL clear yellow urine

Total blood loss of 800 mL

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

200 mL blood loss

Fundus remains firm with slight lochia noted on pad

Answer and Explanation

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

At risk of hypovolemia

D. Total blood loss of 800 mL

A total blood loss of 800 mL indicates significant hemorrhage, which puts the client at risk for hypovolemia (low blood volume). While exact definitions may vary, typically, blood loss exceeding 500 mL postpartum is considered significant and increases the risk of hypovolemia if not managed appropriately.

F. 200 mL blood loss

While 200 mL of blood loss is within the normal range for immediate postpartum period, it still represents a loss of blood that, if ongoing, could potentially lead to hypovolemia if not monitored closely.

Condition has improved

A. Fundus massaged until firm and at umbilicus

Massaging the fundus until it is firm and at the umbilicus helps ensure uterine contraction, which reduces the risk of excessive bleeding and promotes hemostasis. This indicates that uterine tone is adequate, which is a positive sign.

C. Straight catheter produced 500 mL clear yellow urine

The passage of 500 mL of clear yellow urine indicates adequate renal perfusion and hydration status, suggesting that the client's fluid balance is being maintained or improved, which is important in preventing hypovolemia.

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

Stable vital signs with normal blood pressure, heart rate, and oxygen saturation indicate adequate perfusion and oxygenation. This suggests that the client's condition is stable and not immediately at risk for hypovolemia.

G. Fundus remains firm with slight lochia noted on pad

A firm fundus with slight lochia (postpartum vaginal discharge) indicates ongoing normal involution (shrinking) of the uterus with minimal bleeding. This suggests that the client's uterus is contracting well, which is favorable for preventing hypovolemia.

Nursing Test Bank

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Correct Answer is C

Explanation

Rationale

A. During a thoracentesis, a needle is inserted through the chest wall into the pleural space to remove fluid or air. It's common for clients to feel a stinging sensation or discomfort during needle insertion. The nurse should confirm this understanding with the client and reassure them that local anesthesia will be used to minimize discomfort.

B. The positioning described (sitting forward with arms propped on a table) helps to expand the intercostal spaces and facilitates easier access to the pleural space during the procedure. The nurse should reinforce this position as appropriate for the thoracentesis procedure.

C. This statement is incorrect and would indicate a need for additional education. A persistent cough is not an expected outcome after a thoracentesis. While some clients may experience a mild cough during or immediately after the procedure due to irritation from the needle or local anesthesia, it should not persist afterwards.

D. This statement is generally correct. After a thoracentesis, it is recommended to limit strenuous activity and avoid heavy lifting for a day or two to minimize the risk of complications such as discomfort or injury at the needle insertion site. The nurse should support this instruction as part of the client's post-procedure care.

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 The nurse is reviewing the client's chart. For each finding, click to indicate whether 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.

D. Total blood loss of 800 mL

F. 200 mL blood loss

A. Fundus massaged until firm and at umbilicus

C. Straight catheter produced 500 mL clear yellow urine

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

G. Fundus remains firm with slight lochia noted on pad

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing a client for an outpatient thoracentesis. Which statement made by the client should the nurse recognize as needing additional education?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

The healthcare provider prescribes the antibiotic cefdinir 300 mg PO every 12 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat?

The nurse is teaching dietary modifications to a client with hypertension. Which product is the best selection to include as part of the client's lunch?

Exhibits Click to specify which client statement or behaviors is most likely associated with each of the listed defense mechanisms. Some statements or behaviors may be consistent with more than one mechanism. Each column must have at least one response selected.

Exhibits Which client statement(s) require(s) follow up teaching by the nurse? Select all that apply.

Exhibits The nurse is reviewing the client's chart. For each finding, click to indicate whether 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.

Exhibits

The nurse is reviewing the client's chart.

For each finding, click to indicate whether 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.