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 D

Explanation

Rationale

A. This approach might inadvertently increase feelings of isolation and worsen agitation. Older adults with dementia often benefit from social interaction and engagement. Limiting interaction could lead to increased confusion and behavioral issues.

B. Attempting to correct or argue with the client about their delusions is generally not effective and can escalate agitation. Clients with dementia may not have the cognitive ability to understand or accept reality as others perceive it. Therefore, trying to clarify or correct delusional thoughts is unlikely to be helpful and may increase distress.

C. While maintaining a consistent routine is beneficial for clients with dementia, forcibly awakening the client earlier could disrupt their natural sleep patterns and contribute to increased confusion and agitation. It's important to balance the need for routine with the client's individual sleep and rest patterns.

D. This approach focuses on redirecting the client's attention away from the distressing thoughts and behaviors. Distraction techniques involve engaging the client in activities or topics that they find enjoyable or comforting. Therapeutic communication skills include active listening, empathy, and validating the client's emotions without reinforcing delusions.

A. gravida 5, para 5, B. delivery of a 9 lb 1 oz (4.1 kg) female C. labor for 25 hours D. epidural for anesthesia E. 4th degree laceration F. Estimated blood loss was 600 mL after delivery G. forceps were used to assist with the delivery H. catheterized for 500 mL of light-yellow urine I. spouse was at the bedside for delivery J. pain was currently at a 4 on a 0 to 10 pain scale

Correct Answer is ["A","B","C","D","E","F","G"]

Explanation

Correct choices;

Gravida 5, para 5 (G5P5)

This means the client has been pregnant 5 times and has given birth 5 times. Multiparity (having had multiple pregnancies and deliveries) is a risk factor for PPH due to uterine overdistension, which can lead to poor uterine tone and difficulty in contracting effectively after delivery.

Delivery of a 9 lb 1 oz (4.1 kg) baby

Larger babies are associated with an increased risk of PPH. The weight of the baby suggests a potentially larger placental surface area and increased uterine distension during pregnancy, which can contribute to uterine atony post-delivery.

Labor for 25 hours

Prolonged labor can lead to uterine exhaustion, where the uterus may not contract effectively after delivery, predisposing the client to PPH.

Forceps-assisted delivery

Instrumental deliveries, including forceps, can cause trauma to the birth canal, including the cervix, vagina, and perineum, increasing the risk of lacerations and bleeding.

Epidural anesthesia

Epidurals can mask the pain associated with uterine atony, which may delay the diagnosis of PPH. It's important to closely monitor uterine tone and blood loss in clients who have had epidurals.

4th degree laceration

Explanation: A 4th degree laceration involves the perineum and extends through the anal sphincter complex. Such extensive trauma increases the risk of significant bleeding postpartum.

Estimated blood loss of 600 mL

Although this is within the normal range of blood loss immediately after delivery, it still signifies that the client has experienced significant hemorrhage, putting her at higher risk for ongoing bleeding.

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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

An older adult client with dementia who is refusing to allow an unlicensed assistive personnel (UAP) to assist in bathing, is becoming increasingly agitated and stating the UAP "wants to hurt me and tie me up." Which approach should the nurse use with the client?

Correct Answer is D

Explanation

Correct Answer is ["A","B","C","D","E","F","G"]

Explanation

Correct choices;

Gravida 5, para 5 (G5P5)

Delivery of a 9 lb 1 oz (4.1 kg) baby

Labor for 25 hours

Forceps-assisted delivery

Epidural anesthesia

4th degree laceration

Estimated blood loss of 600 mL

A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

A client taking temazepam informs the nurse of plans to quit taking the medication due to feelings of "hungover" the next day. Which action should the nurse implement?

An unresponsive victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save the client's life. The client is accompanied by a close friend, but no family members are available. Which action should the nurse take first?

A client has developed atrial fibrillation with a ventricular rate of 150 beats/minute observed via telemetry. The client's blood pressure is 80/40 mm Hg. Which finding is most important for the nurse to report to the healthcare provider?

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.

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

The nurse is preparing for discharge a client with a history of celiac disease who now has developed multiple sclerosis. Which instruction is most important for the nurse to include in the discharge teaching plan?

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.