A nurse is caring for a client who is requesting to go to the bathroom immediately after a vaginal birth. Which of the following actions should the nurse take?
Inform the client that she can go to the bathroom whenever needed.
Advise the client to remain in bed for the next few hours.
Assist the client to the bathroom and assess the lochia.
Evaluate the side effects of any analgesics used during labor.
The Correct Answer is C
b) Return the patient to bed and maintain bed rest until the local flow stabilizes.
Explanation: 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.
a) Maximize funding and avoid undue pressure on the cesarean incision: This option is unrelated to the situation described. It mentions maximizing funding, which is not relevant to the patient's condition, and does not address the sudden guard experienced during bathroom assistance.
b) Adjust fluid consistency and continue to monitor the local flow amount: This option is not applicable to the situation described. It suggests adjusting fluid consistency and monitoring local flow, which do not address the sudden guard experienced by the patient.
c) Withhold bladder emptying until the Foley catheter is removed and contract the fundus: This option is not appropriate for the situation described. It refers to withholding bladder emptying until the Foley catheter is removed, which may not be necessary or relevant in this case. Contracting the fundus is also unrelated to the sudden guard experienced during bathroom assistance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E","F"]
Explanation
Choice A rationale:
Increased temperature alone is not a sufficient indication for pain medication in a post-pyloromyotomy infant. Fever can have various causes, and pain should be assessed based on other factors.
Choice B rationale:
Increased pulse rate can be an indication of pain in an infant following surgery like pyloromyotomy. It's important to assess the overall clinical picture and consider pain management if other signs are present.
Choice C rationale:
Increased respiratory rate alone is not a specific indicator of pain in a post-pyloromyotomy infant. Respiratory rate can vary for many reasons, so it should not be the sole criterion for pain management.
Choice D rationale:
Increased pulse rate is a potential sign of pain in a post-pyloromyotomy infant and should be considered when assessing the need for pain medication.
Choice E rationale:
Restlessness is often a sign of discomfort or pain in infants. Restlessness, along with other clinical indicators, can guide the decision to administer pain medication.
Choice F rationale:
Clenched fists can be a sign of discomfort or pain in infants, and it should be considered when assessing the need for pain management.
Correct Answer is ["30"]
Explanation
Question: How many mL/hour should the nurse program the infusion pump?
Step 1: Convert 176 pounds to kg. 176 lbs ÷ 2.2 = 80 kg
Step 2: Calculate the total mcg per hour. 2 mcg/min × 60 min = 120 mcg/hour
Step 3: Convert mcg to mg. 120 mcg ÷ 1000 = 0.12 mg
Step 4: Calculate the mL/hour. 0.12 mg ÷ (4 mg ÷ 1000 mL) = 30 mL/hour
Answer: 30 mL/hour
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.