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 A
Explanation
Choice A rationale:
The combination of trimethoprim and sulfamethoxazole has a synergistic effect, which means that the two drugs work together to inhibit bacterial growth more effectively than either drug alone. This combination is commonly used to treat urinary tract infections (UTIs) caused by susceptible bacteria.
Choice B rationale:
The combination of trimethoprim and sulfamethoxazole does not have an additive effect that reduces the dosage and frequency of administration of each drug. Instead, it is prescribed as a fixed combination with specific dosages of each drug.
Choice C rationale:
The combination of trimethoprim and sulfamethoxazole does not have an antagonistic effect that prevents the development of resistance to either drug. In fact, the combination is chosen because it covers a broader spectrum of bacteria and reduces the likelihood of resistance development.
Choice D rationale:
The combination of trimethoprim and sulfamethoxazole does not have a selective effect that targets only the bacteria causing the UTI and spares the normal flora. It affects a wide range of bacteria, including both pathogenic and normal flora.
Correct Answer is C
Explanation
The correct answer and explanation is:
c) Administer the medication and document the heart rate.
This is the action that the PN should take prior to giving digoxin to a 2-month-old infant whose heart rate is 120 beats/minute. Digoxin is a cardiac glycoside that is used to treat heart failure and arrhythmias. It has a narrow therapeutic range and can cause serious side effects such as bradycardia, hypotension, and toxicity. Therefore, it is important to monitor the client's vital signs before and after administering the medication. A normal heart rate for a 2-month-old infant is 100–190 beats/minute, so 120 beats/minute is within the normal range and does not indicate a need to hold the medication. The PN should administer the medication as prescribed and document the heart rate and any other relevant findings.
a) Administer the medication and alert the charge nurse.
This is not the action that the PN should take prior to giving digoxin to a 2-month-old infant whose heart rate is 120 beats/minute. Alerting the charge nurse is not necessary, as the heart rate is normal and does not indicate a problem with the medication or the client's condition. The PN should administer the medication as prescribed and document the heart rate and any other relevant findings.
b) Hold the medication and document cardiac assessment.
This is not the action that the PN should take prior to giving digoxin to a 2-month-old infant whose heart rate is 120 beats/minute. Holding the medication is not appropriate, as the heart rate is normal and does not indicate a contraindication or a risk of adverse effects from the medication. The PN should administer the medication as prescribed and document the heart rate and any other relevant findings.
d) Hold the medication and recheck the heart rate in 1 hour.
This is not the action that the PN should take prior to giving digoxin to a 2-month-old infant whose heart rate is 120 beats/minute. Holding the medication and rechecking the heart rate in 1 hour is not necessary, as the heart rate is normal and does not indicate a need for further evaluation or intervention. The PN should administer the medication as prescribed and document the heart rate and any other relevant findings.
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