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

Answer and Explanation

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.

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Correct Answer is ["A","B","E"]

Explanation

Choice A rationale

Removing resuscitation equipment from the room is a standard practice before allowing family members to view the body after an unsuccessful resuscitation. This helps to create a more peaceful and less distressing environment for the family. It also respects the dignity of the deceased and allows the family to focus on their loved one, rather than the medical interventions that were attempted.

Choice B rationale

Placing a small pillow under the head is a common practice in preparing the body for viewing by the family. This helps to position the body in a natural and peaceful manner, which can be comforting for the family. It also respects the dignity of the deceased.

Choice E rationale

Gently closing the eyes is another common practice in preparing the body for viewing by the family. This helps to give the appearance of peaceful rest, which can be comforting for the family. It also respects the dignity of the deceased.

Choice C rationale

Taking out dentures and placing them in a labeled cup is not a standard practice in preparing the body for viewing by the family. Dentures, if present, are usually left in place to maintain the natural appearance of the face.

Choice D rationale

Applying a body shroud is not a common practice in preparing the body for viewing by the family. The use of a body shroud may vary based on cultural or religious preferences, but it is not a standard procedure in many healthcare settings.

A. Provide counseling that most contraceptives protect against infection. B. Clarify that all STIs are transmitted through sexual intercourse. C. Emphasize that using safe sex practices removes the risk of STIs. D. Explain that reinfections occur from sex with untreated partners.

Correct Answer is D

Explanation

Choice A rationale

While it’s true that many contraceptives can help prevent certain sexually transmitted infections (STIs), they are not 100% effective. Condoms, for instance, can reduce the risk of STIs that are spread through bodily fluids, such as gonorrhea and chlamydia. However, they are less effective at protecting against STIs that are transmitted through skin-to-skin contact, such as herpes and human papillomavirus (HPV)1.

Choice B rationale

Not all STIs are transmitted through sexual intercourse. Some STIs, such as herpes and HPV, can be spread through skin-to-skin contact. Others, like HIV and hepatitis B and C, can also be spread through sharing needles or from mother to child during childbirth.

Choice C rationale

Safe sex practices can significantly reduce, but not completely remove, the risk of STIs. These practices include using condoms correctly every time you have sex, getting tested regularly for STIs, and limiting the number of sexual partners.

Choice D rationale

Reinfections can indeed occur from having sex with untreated partners. This is particularly true for bacterial STIs like syphilis. If a person’s partner is not treated, the bacteria can remain in their body and they can pass the infection back to the person after they’ve been treated.

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The nurse is reviewing the nurse’s notes and flow chart to identify trends.Which notations require immediate follow-up?

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Naxlex Comprehensive Predictor Exams

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased.The family wishes to see the body before it is taken to the funeral home.Which interventions should the nurse take to prepare the body before the family enters the room? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis.The client reports having unprotected sex.Which response should the nurse provide?

Correct Answer is D

Explanation

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An older adult client informs the nurse of having a high-density lipoprotein (HDL) level of 85 mg/dL (2.2 mmol/L). What action should the nurse take?

The nurse has reviewed the patient’s chart.The nurse recognizes that this patient is hemorrhaging due to which condition?

A child weighing 55 lb has been prescribed cefotaxime at a dosage of 150 mg/kg/day, to be administered in divided doses every 6 hours. How many mg should the nurse administer each day? (Provide a numerical value only.)

The nurse is working on an infectious disease unit.Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

A patient with a recent exacerbation of heart failure is feeling uncomfortable and anxious, with a sensation of flopping in the chest.While waiting for an electrocardiogram (ECG), which assessment should the nurse prioritize?

The nurse is reviewing the nurse’s notes and flow chart to identify trends.
Which notations require immediate follow-up?