The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection?

White Blood Cell (WBC. Reference Range: 5000-10,000/mm^3 (5-10 x 10^9/L)

Moderate amount of foul-smelling lochia.

Blood pressure of 122/74 mm Hg

Oral temperature of 100.2°F (37.9°C..

White blood cell count of 19,000/mm^3 (19 x 10^9/L)

Answer and Explanation

The Correct Answer is A

Choice B reason: Blood pressure of 122/74 mm Hg is within the normal range for a postpartum client and does not indicate an infection. However, the nurse should monitor for signs of preeclampsia or eclampsia, such as hypertension, proteinuria, headache, blurred vision, and seizures.

Choice C reason: Oral temperature of 100.2°F (37.9°C. is slightly elevated, but not necessarily indicative of an infection. A mild fever may occur within the first 24 hours after delivery due to dehydration or hormonal changes. However, if the fever persists or increases, the nurse should suspect an infection and notify the healthcare provider.

Choice D reason: White blood cell count of 19,000/mm^3 (19 x 10^9/L) is higher than the normal range, but not necessarily indicative of an infection. A leukocytosis or increased WBC count may occur as a normal response to stress or trauma during delivery. However, if the WBC count remains elevated or increases further, the nurse should suspect an infection and notify the healthcare provider.

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Correct Answer is D

Explanation

Choice A: Advising the client to place one nitroglycerin tablet under his tongue as a precaution is a dangerous action for the nurse, as this can cause severe hypotension and cardiovascular collapse due to the interaction between tadalafil and nitroglycerin. This is a contraindicated choice.

Choice B: Telling the client to have someone bring him to an emergency department immediately is an unnecessary action for the nurse, as there is no evidence of any serious adverse reaction or complication from tadalafil. This is an overreaction choice.

Choice C: Instructing the client to increase his intake of oral fluids until the skin flushing is relieved is not an appropriate action for the nurse, as this does not address the cause of the flushing, which is vasodilation due to tadalafil. This is a distractor choice.

Choice D: Reassuring the client that skin flushing is a common side effect of the medication is an appropriate action for the nurse, as this can calm the client and educate him about the expected effects of tadalafil. Therefore, this is the correct choice.

A. Increase the intake of dark green leafy vegetables while taking warfarin. B. Eat two servings of dark green leafy vegetables daily and continue for 30 days after warfarin therapy is completed. C. Eat approximately the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent. D. Avoid eating any foods that contain any vitamin K because it is an antagonist of warfarin.

Correct Answer is C

Explanation

Choice A reason: Increasing the intake of dark green leafy vegetables while taking warfarin is not a good instruction because it can decrease the effectiveness of warfarin. Dark green leafy vegetables are rich in vitamin K, which is a coagulation factor that counteracts the anticoagulant effect of warfarin.

Choice B reason: Eating two servings of dark green leafy vegetables daily and continuing for 30 days after warfarin therapy is completed is not a good instruction because it can cause bleeding complications. Dark green leafy vegetables are rich in vitamin K, which is a coagulation factor that counteracts the anticoagulant effect of warfarin. Stopping warfarin while continuing to eat high amounts of vitamin K can increase the risk of clot formation and thromboembolism.

Choice D reason: Avoiding eating any foods that contain any vitamin K because it is an antagonist of warfarin is not a good instruction because it can cause bleeding complications. Dark green leafy vegetables are rich in vitamin K, which is a coagulation factor that counteracts the anticoagulant effect of warfarin. Eliminating vitamin K from the diet can increase the sensitivity to warfarin and cause excessive bleeding and bruising.

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The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection?White Blood Cell (WBC. Reference Range: 5000-10,000/mm^3 (5-10 x 10^9/L)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A male client reports to the on-call clinic nurse that he took tadalafil 10 mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina, but denies experiencing any current or recent chest pain. Which action should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection?

White Blood Cell (WBC. Reference Range: 5000-10,000/mm^3 (5-10 x 10^9/L)