Try Naxlex NCLEX-RN (Free-Trial)

Exhibits

The nurse reviews the nurse's notes and flow chart to identify trends.

Click to specify the notations that require immediate follow up (more than one notation may be correct.)

Body System

Circulatory

Heart rate 96 beats/minute

Blood pressure 90/62 mm Hg

IV infusing at 125 ml/hr

Respirations 16 breaths/minute

Respiratory

Oxygen saturation of 89%

Several deep breaths

Integumentary

Episiotomy intact with no redness

Pad is saturated with blood

18 gauge IV to left forearm

Genital/Urinary

Boggy fundus 1 cm above umbilicus

Fundus rotated to the right

Voided 200 mL of clear yellow urine

Blood pressure 90/62 mm Hg

Oxygen saturation of 89%

Fundus rotated to the right

Voided 200 mL of clear yellow urine

Oxygen saturation of 89%

IV infusing at 125 ml/hr

Answer and Explanation

The Correct Answer is ["A","B","C"]

Blood pressure 90/62 mm Hg

A blood pressure of 90/62 mm Hg indicates hypotension, which could be indicative of hypovolemia (low blood volume) due to postpartum hemorrhage. Hypotension needs immediate evaluation and intervention to prevent further complications.

Oxygen saturation of 89%

An oxygen saturation of 89% on room air is below the normal range (typically 95-100%). This suggests the client is not adequately oxygenating, which could be due to various reasons such as respiratory compromise or inadequate ventilation. Immediate follow-up is necessary to determine the cause and initiate appropriate interventions.

Fundus rotated to the right

The displacement of the fundus could be due to the presence of a distended bladder pushing the uterus to one side which may increase uterine atony.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale

A. Iodinated contrast dye is commonly used in IVP procedures. Clients with a known allergy to iodine or shellfish may be at increased risk of an allergic reaction to the contrast dye. It is crucial to notify the healthcare provider so that appropriate pre-medication or alternative imaging options can be considered to minimize the risk of an allergic reaction.

B. While some procedures may require a urinary catheter, it is not routinely necessary for an IVP. Urinary catheters are generally used when precise urinary output measurement is required or when there are concerns about bladder function during and after the procedure. There is no specific indication for routine urinary catheterization before an IVP.

C. Drinking plenty of fluids before an IVP helps to ensure adequate hydration and can help flush the contrast dye from the body more quickly after the procedure. This can help reduce the risk of contrast dye-related complications such as nephrotoxicity and contrast-induced nephropathy.

D. After an IVP, there is no requirement for the client to keep their legs straight for an extended period. Typically, clients are observed for a brief period after the procedure to monitor for any immediate adverse reactions, but they are not required to keep their legs straight or remain immobile for an extended duration.

A. Finish the procedure. B. Close the room door. C. Call for an assistant. D. Respond to the code.

Correct Answer is D

Explanation

Rationale

A. Continuing with the tracheostomy care procedure while a code blue is ongoing for another client is not appropriate. A code blue takes precedence as it indicates a life-threatening emergency requiring immediate response.

B. Closing the room door is not a priority action during a code blue. The immediate focus should be on responding to the emergency and providing assistance as needed.

C. If additional help is needed to assist with the tracheostomy care procedure, calling for an assistant could be appropriate under normal circumstances. However, during a code blue, the primary responsibility is to respond to the emergency immediately.

D. A code blue indicates a cardiac or respiratory arrest, which requires immediate intervention. As a nurse, responding to the code blue involves providing assistance with cardiopulmonary resuscitation (CPR), fetching emergency equipment, and supporting the healthcare team in resuscitative efforts.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When preparing a client for an intravenous pyelogram (IVP), it is essential for the nurse to take which action?

Correct Answer is A

Explanation

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

Correct Answer is D

Explanation

While preparing to administer a scheduled IV medication, the client tells the nurse that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement?

Exhibits After the nurse assesses the client, the healthcare provider writes prescriptions. The nurse reviews the prescriptions. Which 2 prescriptions should the nurse complete 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?

The nurse is assessing a 3-month-old client who had a pyloromyotomy yesterday. This child should be medicated for pain based on which finding(s)? Select all that apply.

A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath with activity. Which test should the nurse schedule the client for evaluation of the symptoms?

While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

After a scheduled downtime, the computer documentation system fails to restart. Which action should the nurse take first?

Exhibits The nurse discusses the keep to balance energy intake and output to maintain weight Click to indicate whether the following actions would be effective or ineffective for this client to achieve energy balance. Each row must have one option selected.