The practical nurse (PN) receives change of shift report on a postpartum unit. Which client should receive the PN's attention first?

A client who needs to ambulate to the bathroom for the first time since the birth of her infant.

A client prepared for discharge who has a question about the teaching she received the day before.

A client with twins who is tired and would like her babies returned to the newborn nursery.

A post cesarean client with a prescription to have her indwelling urinary and intravenous

Answer and Explanation

The Correct Answer is A

A. A client who needs to ambulate for the first time since delivery requires the PN’s immediate attention to ensure safety and prevent complications such as orthostatic hypotension or falls.
B. A client prepared for discharge who has a question about teaching is important but does not take precedence over immediate safety concerns related to the client’s physical activity.
C. A tired client with twins who would like her babies returned to the nursery is important for the client’s well-being, but it is not as urgent as ensuring the safety of a postpartum client beginning to ambulate.
D. Removing indwelling urinary and intravenous catheters is important but not as urgent as ensuring the safety of a client ambulating for the first time after birth.

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Correct Answer is C

Explanation

A. Observing for signs of pain or discomfort during the treatment is not a direct method for evaluating ondansetron’s effectiveness. Ondansetron is used to prevent nausea and vomiting, not to manage pain.
B. While assessing vital signs is important for overall monitoring, it does not specifically measure the effectiveness of ondansetron for preventing nausea and vomiting.
C. Monitoring for nausea or vomiting following the treatment is the most direct way to evaluate the effectiveness of ondansetron. The primary goal of ondansetron is to prevent or reduce these symptoms associated with chemotherapy.
D. Evaluating if the client feels calm and relaxed is not a measure of ondansetron’s effectiveness. The focus should be on the medication’s ability to prevent nausea and vomiting rather than the client's emotional state before treatment.

A. Heart rate 99 beats/minute B. Dark, yellow urine C. Urinated 30 mL D. Temperature 101° F (38.3° C)

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

Explanation

A. Heart rate 99 beats/minute
A heart rate of 99 beats/minute is slightly elevated. Tachycardia can be a sign of fluid volume deficit, as the body compensates for decreased blood volume and pressure by increasing heart rate to maintain adequate perfusion.
B. Dark, yellow urine
Dark yellow urine indicates concentrated urine, which is a sign of dehydration or fluid volume deficit. Proper hydration would typically result in light yellow urine.
C. Urinated 30 mL
A urine output of 30 mL is low, especially for an adult in a 1-hour period. Low urine output can be a sign of fluid volume deficit, as the kidneys may not be excreting enough urine due to inadequate fluid intake or retention.
D. Temperature 101° F (38.3° C)
An elevated temperature indicates a fever, which is related to the infection (pneumonia) rather than fluid volume status. It does not directly indicate a fluid volume deficit.
E. Client is awake and alert
Being awake and alert indicates that the client’s neurological status is stable and is not indicative of fluid volume deficit. It does not reflect the client’s fluid volume status.
F. Blood pressure 115/71 mm Hg
A blood pressure of 115/71 mm Hg is within normal limits. While fluid volume deficits can affect blood pressure, this finding alone does not indicate a deficit since the blood pressure is stable.

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The practical nurse (PN) receives change of shift report on a postpartum unit. Which client should receive the PN's attention first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives ondansetron prior to a chemotherapy treatment. How should the practical nurse evaluate the effectiveness of the medication?

Correct Answer is C

Explanation

Exhibits Following the infusion of sodium chloride, the practical nurse (PN) does a focused assessment and documents the findings. Which three of the following client findings indicate that the client may still have a fluid volume deficit?

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

Explanation

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