A patient is being assisted to the bathroom for the first time after Caeserean delivery. A recent experience caused a sudden fall made the client end up at the hospital. The options for the practical nurse (PN) are:
Maximize resting and avoid undue pressure on the cesarean incision.
Return the patient to bed and maintain bed rest until the local flow stabilizes.
Adjust IV fluid flow rate 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 B
Explanation
Smokeless tobacco, such as chewing tobacco or snuff, still contains harmful substances, including nicotine and various chemicals. It is associated with several health risks, including an increased risk of oral, esophageal, and pancreatic cancers, as well as gum disease, tooth loss, and nicotine addiction.
Incorrect:
A. By providing this information, the nurse can help the client make an informed decision about their smoking cessation plan. It is crucial to emphasize that quitting tobacco altogether is the best approach to reduce the risk of cancer and improve overall health.
C. The nurse should not encourage the client to continue with the plan to switch to smokeless tobacco as a means of reducing the risk for cancer. Instead, the focus should be on supporting the client's efforts to quit tobacco entirely and providing appropriate resources and interventions to facilitate smoking cessation.
D. Addressing the concern about weight gain when quitting smoking is also important, but it should be done in the context of promoting healthy lifestyle changes and offering strategies to manage weight during the smoking cessation process.
Correct Answer is C
Explanation
Choice A reason:
Administering the medication and alerting the charge nurse is not necessary in this scenario. The heart rate of 120 beats/minute is within the normal range for a 2-month-old infant, which is typically between 80 to 160 beats per minute. Therefore, there is no immediate concern that would require alerting the charge nurse.
Choice B reason:
Holding the medication and documenting the cardiac assessment would be appropriate if the heart rate were outside the normal range or if there were other signs of digoxin toxicity or adverse effects. Since the heart rate is within the normal range, this action is not warranted.
Choice C reason:
Administering the medication and documenting the heart rate is the correct action. The heart rate of 120 beats/minute falls within the normal range for a 2-month-old infant¹². Digoxin is prescribed to manage certain heart conditions, and as long as the heart rate is within the normal range and there are no signs of toxicity, the medication should be given as prescribed.
Choice D reason:
Holding the medication and rechecking the heart rate in 1 hour would be considered if the heart rate were borderline or if there were concerns about the stability of the infant's condition. Since the heart rate is stable and within the normal range, this action is unnecessary.
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