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 {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
Based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of Stroke as evidenced by Neurological defects and Garbled speech. The symptoms of facial drooping, garbled speech, and high blood pressure are common signs of a stroke. However, it’s important to get a professional medical diagnosis as soon as possible. Please seek immediate medical attention.
Choice A rationale:
Intoxication is a plausible explanation for the client’s symptoms, especially given the report of alcohol consumption. However, intoxication typically does not cause facial drooping, which is a common sign of neurological issues such as a stroke. Therefore, while intoxication may contribute to the client’s condition, it is not the most likely primary cause.
Choice B rationale:
Stroke is a medical emergency that often presents with facial drooping and garbled speech, both of which are observed in this client. A stroke occurs when blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients. This can lead to brain cells dying in minutes. The client’s high blood pressure (210/98 mm Hg) is a significant risk factor for stroke. Normal blood pressure ranges from 90/60 mm Hg to 120/80 mm Hg.
Choice C rationale:
An allergic reaction could cause various symptoms, but it typically does not result in facial drooping or garbled speech. Common signs of an allergic reaction include hives, itching, redness, and swelling of the skin, as well as difficulty breathing in severe cases (anaphylaxis). There is no mention of these symptoms in the client’s presentation.
Choice D rationale:
Malignant hypertension is a possibility given the client’s extremely high blood pressure reading. This condition refers to severe hypertension that can quickly lead to organ damage. However, while it can cause neurological symptoms if it leads to a hypertensive crisis, the specific symptoms of facial drooping and garbled speech are more indicative of a stroke. In conclusion, based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of a stroke as evidenced by neurological defects (facial drooping and garbled speech). The client’s high blood pressure and reported alcohol consumption are both risk factors for stroke. Immediate medical intervention is crucial to minimize brain damage and potential complications.
Correct Answer is B
Explanation
Choice A rationale:
Increasing the supplemental oxygen to 15 L/min via nasal cannula may seem like a logical step given the client’s low oxygen saturation. However, it’s important to note that oxygen therapy should be titrated carefully. Too much oxygen can lead to oxygen toxicity, which can cause cellular damage and worsen the client’s condition. Therefore, this is not the priority action.
Choice B rationale:
Notifying the health care provider of the client’s condition is the priority action. The client’s oxygen saturation is 88% on room air, which is below the normal range of 95% to 100%. This indicates that the client is not getting enough oxygen, which can lead to hypoxia and other serious complications. The health care provider needs to be informed immediately so that appropriate interventions can be initiated.
Choice C rationale:
Administering ibuprofen as ordered for fever is important, but it’s not the priority in this situation. While fever can indicate an infection, which could be contributing to the client’s low oxygen saturation, addressing the immediate issue of hypoxia is more critical.
Choice D rationale:
Obtaining a sputum culture from the client could provide valuable information about the type of bacteria causing the pneumonia and guide antibiotic therapy. However, this is not an immediate priority compared to addressing the client’s low oxygen saturation. In summary, while all these actions are important in caring for a client with pneumonia, the nurse must prioritize interventions based on their urgency and potential impact on the client’s health status. In this case, notifying the health care provider of the client’s condition is the most critical action.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.