The practical nurse (PN) observes an unlicensed assistive personnel (UAP) bathing a bedfast client with the bed in the high fowlers position. Which action should the PN take?

Assume care of the client immediately.

Remain in the room to supervise the UAP.

Instruct the UAP to lower the bed for safety.

Determine if the UAP would like assistance.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C: Instruct the UAP to lower the bed for safety.

Choice C rationale: When bathing a bedfast client, the bed should be in a flat or low position to reduce the risk of the client sliding down, falling, or experiencing discomfort or injury. By instructing the UAP to lower the bed, the PN ensures client safety during the bathing process.

Choice A rationale: Assuming care of the client immediately might be unnecessary. The PN should first address the safety concern and then determine if additional intervention is needed.

Choice B rationale: While supervising the UAP may be appropriate in certain situations, the priority in this case is to address the immediate safety concern by instructing the UAP to lower the bed. The PN can then decide if supervision or assistance is required.

Choice D rationale: Determining if the UAP would like assistance is considerate, but it is not the priority in this situation. Ensuring client safety by lowering the bed should be addressed first. The PN can then assess whether the UAP needs any help or guidance.

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Correct Answer is D

Explanation

The correct answer and explanation is:

d) Massage the fundus and avoid direct pressure on the cesarean incision.

This is the best action to take for a client who experiences a sudden gush of vaginal blood and clots after a

cesarean section. Massaging the fundus helps to stimulate uterine contractions and reduce bleeding.

Avoiding direct pressure on the incision prevents pain and wound dehiscence.

a) Insert an indwelling catheter to empty the bladder and contract the fundus.

This is not the first action to take for a client who experiences a sudden gush of vaginal blood and clots after a cesarean section. Inserting an indwelling catheter requires a physician's order and may cause discomfort and infection. The client may already have a catheter in place after the surgery.

b) Check fundal consistency and continue to monitor the lochial ﬂow amount.

This is not enough to do for a client who experiences a sudden gush of vaginal blood and clots after a cesarean section. Checking fundal consistency and monitoring lochial ﬂow are important, but they do not address the cause of bleeding or prevent further blood loss.

c) Return the client to bed and maintain bedrest until the lochial ﬂow slows.

This is not appropriate for a client who experiences a sudden gush of vaginal blood and clots after a cesarean section. Returning the client to bed and maintaining bedrest may delay ambulation and increase the risk of thromboembolism. It also does not stop the bleeding or treat the underlying cause.

A. Decrease expiratory flow time. B. Decrease expiratory pressure. C. Increase rate of ventilation. D. Increase ventilator tidal volume.

Correct Answer is B

Explanation

Choice A rationale:

Decreasing expiratory flow time is not the appropriate intervention in this case. The client's pH and PaCO2 levels suggest respiratory acidosis, which indicates inadequate ventilation. Increasing expiratory flow time might exacerbate the acidosis by reducing ventilation.

Choice C rationale:

Increasing the rate of ventilation (respiratory rate) is a potential intervention to improve the client's acid-base balance. However, it should be done cautiously and under medical supervision to avoid respiratory alkalosis. It is not the first-line intervention in this scenario.

Choice D rationale:

Increasing the ventilator tidal volume may help improve ventilation, but it should also be done under medical guidance to prevent barotrauma. It is not the initial intervention to address the client's respiratory acidosis.

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The practical nurse (PN) observes an unlicensed assistive personnel (UAP) bathing a bedfast client with the bed in the high fowlers position. Which action should the PN take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

On the first day after a cesarean section, a client who is a primipara is being assisted to the bathroom for the first time. The client experiences a sudden gush of vaginal blood and notices that several blood clots are in the toilet. Which action should the practical nurse (PN) take?

Correct Answer is D

Explanation

Reference Range: 1329545.A client receiving mechanical ventilation has a pH of 7.26, PaCO2 of 68 mm Hg, and a PaO2 of 92 mm Hg. Which intervention should the nurse implement?

Correct Answer is B

Explanation

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