The patient is being assisted to the bathroom for the first time. The recent experience caused a sudden guard and ended up at the hospital. The options for the practical course (PN) are:
Maximize funding and avoid undue pressure on the cesarean incision.
Return the patient to bed and maintain bed rest until the local flow stabilizes.
Adjust fluid consistency and continue to monitor the local flow amount.
Withhold bladder emptying until the Foley catheter is removed and contract the fundus.
The Correct Answer is B
The patient experienced a sudden guard while being assisted to the bathroom, which led to their hospitalization. The most appropriate action for the practical nurse (PN) in this situation is to prioritize the patient's safety and well-being. Returning the patient to bed and maintaining bed rest allows for stability and minimizes the risk of further complications or injury. By providing a safe and controlled environment, the PN can monitor the patient's condition and collaborate with the healthcare team to determine the appropriate course of action moving forward.
Options a), c), and d) are not relevant or appropriate in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Heart rate of 90 beats per minute with premature ventricular contractions (PVCs) noted on telemetry: This finding indicates an abnormality in the heart's electrical conduction system. PVCs are extra, abnormal heartbeats that originate in the ventricles. They can sometimes be benign, but they can also be associated with underlying heart conditions or electrolyte imbalances. Since the client is experiencing dizziness and tingling, which could be related to cardiac function, it is important to report this finding to the healthcare provider for further evaluation and appropriate management.
Incorrect:
A. Regular heart rate of 100 beats per minute on telemetry: This finding describes a heart rate within the normal range (60-100 beats per minute for adults). It does not indicate any immediate concerns or abnormalities that would require reporting to the healthcare provider in this context.
B. Hypoactive bowel sounds on assessment: Following a small bowel resection, it is common for bowel sounds to be temporarily reduced or absent due to the surgical manipulation and the bowel's response to anesthesia. Hypoactive bowel sounds alone do not directly relate to the client's reported symptoms of dizziness and tingling in digits, nor do they suggest an immediate need for reporting to the healthcare provider.
D. Hyperactive bowel sounds on assessment: Hyperactive bowel sounds, characterized by increased loudness and frequency, can occur due to conditions such as gastroenteritis or bowel obstruction. However, in the context of a client who has undergone a small bowel resection and is on NPO status, hyperactive bowel sounds would not be expected and may indicate a potential complication. While it is important to monitor and document this finding, it is not directly related to the client's reported symptoms and does not require immediate reporting to the healthcare provider in this scenario.
Correct Answer is ["500"]
Explanation
1 liter is equal to 1000 milliliters. Therefore, to calculate the fluid intake in mL, we can multiply 1/2 liter by 1000 mL/liter:
1/2 liter * 1000 mL/liter = 500 mL
So, the practical nurse should document 500 mL as the client's fluid intake.
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