The nurse is reviewing the nurse’s notes and flow chart to identify trends.
Which notations require immediate follow-up?
Boggy fundus 1 cm above the umbilicus
Fundus rotated to the right
Voided 200 mL of clear yellow urine
Blood pressure 90/62 mm Hg
Correct Answer : A,B
Choice A rationale
A boggy fundus refers to an enlarged, soft, and tender uterus identified during physical examination. It is most commonly caused by uterine atony or adenomyosis. A boggy fundus 1 cm above the umbilicus requires immediate follow-up as it indicates that the uterus is not contracting properly after childbirth, which can lead to postpartum hemorrhage.
Choice B rationale
A fundus rotated to the right could indicate a distended bladder. This requires immediate follow-up as it can lead to urinary retention and other complications.
Choice C rationale
Voiding 200 mL of clear yellow urine is a normal finding and does not require immediate follow-up.
Choice D rationale
A blood pressure of 90/62 mm Hg is considered normal according to the American Heart Association. Therefore, it does not require immediate follow-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D rationale
In a patient with severe ulcerative colitis who has undergone surgery for a fistula repair, replacing fluids IV based on intake and output is the most important intervention to include in the plan of care. This is because patients with ulcerative colitis often experience significant fluid and electrolyte imbalances due to diarrhea and other gastrointestinal losses. Following surgery, these imbalances can be further exacerbated by factors such as fasting, surgical stress, and the use of certain medications. Therefore, careful monitoring of fluid and electrolyte balance, and appropriate IV fluid replacement, is crucial to prevent complications such as dehydration, electrolyte imbalances, and renal dysfunction.
Correct Answer is ["1.32"]
Explanation
Step 1 is to convert the patient’s weight from pounds to kilograms. There are approximately 2.2046 pounds in 1 kilogram. So, the patient’s weight in kilograms is 132 lb ÷ 2.2046 = 59.87 kg.
Step 2 is to calculate the total dose of lorazepam the patient should receive. The prescribed dose is 44 mcg/kg. So, the total dose in micrograms is 44 mcg/kg × 59.87 kg = 2634.28 mcg.
Step 3 is to convert the total dose from micrograms to milligrams. There are 1000 micrograms in 1 milligram. So, the total dose in milligrams is 2634.28 mcg ÷ 1000 = 2.63428 mg.
Step 4 is to calculate the volume of lorazepam solution to administer. The concentration of the solution is 2 mg/mL. So, the volume in milliliters is 2.63428 mg ÷ 2 mg/mL = 1.31714 mL. Therefore, the nurse should administer approximately 1.32 mL of the lorazepam solution, rounding to the nearest hundredth as required.
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