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.

Answer and Explanation

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.

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

Explanation

Choice A rationale:

Stopping the heparin infusion immediately is essential when the client's aPTT is significantly elevated (in this case, 120 seconds). A prolonged aPTT indicates a higher risk of bleeding, and discontinuing the heparin infusion is a crucial step in preventing further bleeding.

Choice B rationale:

Administering protamine sulfate is necessary when a client on heparin therapy experiences excessive bleeding or if the aPTT is significantly elevated. Protamine sulfate acts as a heparin antagonist and can reverse the anticoagulant effects of heparin.

Choice C rationale:

Notifying the healthcare provider of the significantly prolonged aPTT is essential because it may indicate a need for adjustments in the heparin dosage or therapy. The provider can determine the appropriate course of action based on the client's clinical condition.

Choice D rationale:

Drawing a prothrombin time (PT) and international normalized ratio (INR) level is not necessary in this situation. PT and INR are more relevant parameters when assessing clients on warfarin therapy, not heparin.

Choice E rationale:

Monitoring the client for signs and symptoms of bleeding is crucial when the aPTT is prolonged, as it indicates a higher risk of bleeding. This action allows for early detection and intervention to prevent complications.

A. Gather information regarding how long it will take for the children to arrive. B. Explain that the client will start to lose consciousness and the body systems will slow down. C. Offer to discuss the client's health status with each of the adult children. D. Reassure the spouse that the healthcare provider will notify when to call the children.

Correct Answer is B

Explanation

Choice B rationale:

Choice A rationale:

Gathering information regarding how long it will take for the children to arrive is important but does not address the immediate need for information on the dying process.

Choice C rationale:

Offering to discuss the client's health status with each of the adult children is a good approach for involving them in their father's care but does not provide the immediate information the wife is seeking.

Choice D rationale:

Reassuring the spouse that the healthcare provider will notify when to call the children does not offer information about the dying process itself, which is what the wife is interested in understanding.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory results of a client who is receiving intravenous unfractionated heparin.The nurse notes that the client’s activated partial thromboplastin time (aPTT) is 120 seconds.What are the appropriate nursing actions in this situation? Select all that apply.*.

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

Explanation

An adult male was diagnosed with stage IV lung cancer three weeks ago.His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies.Which is the best response by the nurse?

Correct Answer is B

Explanation

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