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 ["B","D"]

Explanation

The correct answer is choice b. Apple juice and d. Chicken broth.

Choice A rationale:

Orange juice is a clear liquid and generally acceptable on a clear liquid diet. However, it is not the best choice for someone following Mormon beliefs due to its acidity, which might not be suitable post-surgery.

Choice B rationale:

Apple juice is a clear liquid and suitable for a clear liquid diet. It is also non-caffeinated and non-alcoholic, aligning with Mormon dietary restrictions.

Choice C rationale:

Hot chocolate contains caffeine and is not considered a clear liquid. It is not suitable for a clear liquid diet and does not align with Mormon dietary restrictions.

Choice D rationale:

Chicken broth is a clear liquid and suitable for a clear liquid diet. It is non-caffeinated and non-alcoholic, making it appropriate for someone following Mormon beliefs.

Choice E rationale:

Black coffee contains caffeine, which is prohibited in the Mormon diet. It is also not recommended on a clear liquid diet.

A. Include the family in the discharge teaching. B. Encourage the client to attend reading classes. C. Face the client when speaking. D. Speak loudly when teaching. E. Provide the daughter with written instructions.

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

Explanation

C. Face the client when speaking.

E. Provide the daughter with written instructions.

Choice A rationale:

Including the family in the discharge teaching is essential, especially when dealing with a client who has communication barriers such as hearing loss and illiteracy. Involving the daughter in the teaching process ensures that she is aware of the client's care needs and can provide support at home.

Choice B rationale:

Encouraging the client to attend reading classes is not a practical intervention for an older adult with hearing loss. Reading classes may not address the immediate communication needs of the client, and the client's primary caregiver, in this case, is the daughter who will provide daily care and support.

Choice C rationale:

Facing the client when speaking is a crucial intervention when dealing with someone who has hearing loss. By facing the client, the nurse ensures that the client can see their lips and facial expressions, which can aid in lip-reading and understanding the communication better.

Choice D rationale:

Speaking loudly when teaching is not always the best approach for clients with hearing loss. While it may seem intuitive to speak loudly, it can distort speech and make it more challenging for the client to understand. Clear and slow speech, along with visual cues, is often more effective.

Choice E rationale:

Providing the daughter with written instructions is essential, especially when the client has limited reading skills. Written instructions can serve as a reference guide for the daughter, helping her provide care and support to her father accurately.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu item(s) should the nurse request for this client? (Select all that apply).

Correct Answer is ["B","D"]

Explanation

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

Explanation

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