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 C
Explanation
Choice A rationale:
Procuring platelet products from the blood bank is a task that should be performed by a licensed nurse, not an unlicensed assistive personnel (UAP). It involves assessing the client's needs, verifying orders, and administering the product, which require nursing judgment and skills.
Choice B rationale:
Titrating oxygen to prescribed parameters is a nursing task that requires clinical judgment, especially if the client's condition changes. UAPs do not have the training or scope of practice to adjust oxygen levels. This task should be assigned to a licensed nurse.
Choice D rationale:
Inserting a urinary catheter, even for an uncomplicated client, is a task that should be performed by a licensed nurse. It involves the potential risk of infection and injury, and it requires sterile technique and assessment of the client's condition. UAPs do not have the training or scope of practice to insert urinary catheters.
Correct Answer is A
Explanation
Choice A rationale:
Encouraging the client to face their fear gradually is an appropriate nursing intervention for a client with a phobia. This approach is consistent with exposure therapy, which is a widely recognized and effective treatment for phobias. Exposure therapy involves gradually exposing the client to the feared object or situation in a controlled and supportive environment. By doing so, the client can learn to confront and manage their fear over time. This approach is evidence-based and helps the client build resilience and reduce anxiety.
Choice B rationale:
Administering benzodiazepines as needed for acute anxiety (Choice B) is not the first-line treatment for phobias. While benzodiazepines can provide temporary relief from anxiety symptoms, they do not address the underlying phobia and can lead to dependence and tolerance with prolonged use. Moreover, they are generally reserved for acute anxiety episodes and not considered a primary treatment for phobias.
Choice C rationale:
Providing psychoeducation about the causes and effects of phobias (Choice C) is a valuable component of treatment, but it alone may not be sufficient. Psychoeducation can help clients understand the nature of their phobia and reduce stigma, but it should be combined with evidence-based therapies like exposure therapy for comprehensive care.
Choice D rationale:
Teaching the client relaxation techniques to manage anxiety (Choice D) can be a helpful adjunct to treatment, but it is not the primary intervention for phobias. Relaxation techniques can be part of a broader strategy to reduce anxiety, but the client also needs exposure therapy or cognitive-behavioral therapy to address the phobia directly.
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