A nurse at the family planning clinic triages several clients over the phone. Which of the following clients should the nurse instruct to come to the clinic?

A client who uses a diaphragm for contraception and has lost 30 lb in the past 6 months dieting

A client who had an intrauterine device (IUD) inserted yesterday and has cramping and bleeding

A client who has started taking oral contraceptives and is experiencing bright red vaginal breakthrough bleeding

A client who has sharp pain in her shoulder following a laparoscopic tubal ligation yesterday

Answer and Explanation

The Correct Answer is D

A. Weight loss while using a diaphragm is not typically an urgent concern and may be related to dieting; the client should be advised to follow up with her primary care provider for further

evaluation.

B. Cramping and bleeding are common side effects following an IUD insertion and typically do not require immediate attention unless severe or accompanied by other concerning symptoms;

the client should be advised to monitor her symptoms and follow up if they worsen.

C. Breakthrough bleeding is a common side effect of starting oral contraceptives and may resolve on its own after a few cycles; the client should be advised to continue taking her pills as prescribed and to follow up if the bleeding persists or worsens.

D. Shoulder pain following a laparoscopic procedure may indicate a potential complication such as referred pain from gas used during the procedure or more serious issues such as internal bleeding or organ injury; the client should be instructed to come to the clinic for further

evaluation and management.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Limit each of the client's visitors to 1 hr per day. - This is not necessary specifically due to the presence of the radiation implant. Visitation restrictions should be based on hospital policy and

the client's condition, not solely on the presence of a radiation implant.

B. Remove dirty linens from the room after double bagging. - This is a standard infection control measure and is not specific to caring for a client with a radiation implant.

C. Wear a dosimeter film badge while in the client's room. - Healthcare workers who care for clients with sealed radiation implants should wear dosimeter film badges to monitor their radiation exposure levels.

D. Ensure family members remain at least 1 m (3.2 feet) from the client. - While limiting exposure to radiation is important, maintaining distance alone may not provide adequate

protection. Healthcare workers should follow appropriate safety precautions and use shielding as necessary when caring for clients with radiation implants.

A. A client who is 2 days postpartum and whose fundus is 2 fingerbreadths below the umbilicus B. A client who is 1 day postpartum and has not voided in 8 hr C. A client who is 3 days postpartum and has not had a bowel movement since prior to admission D. A client who is 4 days postpartum and has lochia serosa

Correct Answer is B

Explanation

A. A fundal height of 2 fingerbreadths below the umbilicus in a client who is 2 days postpartum is within the expected range for that time frame and does not require immediate assessment.

B. A client who is 1 day postpartum and has not voided in 8 hours may be at risk for urinary retention, which can lead to complications such as bladder distension or urinary tract infection. Prompt assessment and intervention are needed.

C. Not having a bowel movement since prior to admission is not an urgent concern in the

immediate postpartum period, especially if the client is otherwise stable and not experiencing discomfort or other symptoms.

D. Lochia serosa, which is the normal vaginal discharge that occurs 3 to 10 days postpartum, is not an urgent concern and does not require immediate assessment.

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A nurse at the family planning clinic triages several clients over the phone. Which of the following clients should the nurse instruct to come to the clinic?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has a sealed radiation implant and is to remain in the hospital for 1 week. Which of the following should the nurse include in the plan of care?

Correct Answer is C

Explanation

A nurse in a postpartum unit is caring for several clients. After receiving a change-of-shift report, which of the following clients should the nurse assess first?

Correct Answer is B

Explanation

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