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","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.

A. Move Client D into an isolation room 24 hours before surgery. B. Ask the dietitian to add a banana to Client C's breakfast tray. C. Increase Client A's oxygen to 4 liters a minute per cannula. D. Verify that Client B has two units of packed cells available.

Correct Answer is D

Explanation

The correct answer is choice d. Verify that Client B has two units of packed cells available.

Choice A rationale:

Moving Client D into an isolation room 24 hours before surgery is not necessary solely based on an elevated WBC count. Elevated WBCs indicate infection or inflammation, but isolation is not typically required unless there is a contagious infection.

Choice B rationale:

Client C’s potassium level of 3.8 mEq/L is within the normal range (3.5 to 5.0 mEq/L). Adding a banana, which is high in potassium, is not necessary.

Choice C rationale:

Client A with emphysema and an oxygen saturation of 94% does not require an increase in oxygen. Oxygen therapy should be carefully managed in clients with emphysema to avoid suppressing their respiratory drive.

Choice D rationale:

Client B has a postoperative hemoglobin of 8.2 mg/dL, which is significantly below the normal range (14 to 18 g/dL). This client may require a blood transfusion to address the low hemoglobin level, making it essential to verify the availability of packed red blood cells.

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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 is assessing a 3-month-old infant who had a pyloromyotomy yesterday. This child should be medicated for pain based on which finding(s)? (Select all that apply.).

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

Explanation

Correct Answer is D

Explanation

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