A nurse is assisting with the care of a client who gave birth.

Exhibits

After review of the medical record of the client, the nurse notes concerning data collection findings.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential Condition:
Uterine atony
Boggy uterus, heavy bleeding, fundus responds to massage but returns to boggy state.

Actions to Take:
Massage fundus.
First-line measure to stimulate contraction and reduce bleeding.
Administer IV oxytocin.
Oxytocin promotes uterine contractions to reduce bleeding.

Parameters to Monitor:
Amount of lochia.
Helps assess ongoing blood loss.
Urine output.
Indicates perfusion status and potential hypovolemia.

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Correct Answer is C

Explanation

A. Delay admission while client fills out form
Admission should proceed; education about advance directives can occur during the process.

B. Confirm with family that consent was signed
Only the client can give informed consent unless they are unable and have a legal surrogate.

C. Determine if the client has prepared their advance directives.
Advance directives should be assessed upon admission to ensure client autonomy is respected.

D. Explain consent form prevents refusal of care
Clients can refuse care at any time, even after signing consent.

A. Wear clean gloves when cleansing the tracheostomy site. B. Cleanse the tracheostomy site with 0.9% sodium chloride. C. Change the client's tracheostomy ties every 72 hr. D. Suction the client's tracheostomy every 6 hr.

Correct Answer is B

Explanation

A. Wear clean gloves when cleansing the tracheostomy site.
Sterile gloves are required in the immediate post-op period to prevent infection.

B. Cleanse the tracheostomy site with 0.9% sodium chloride.
Isotonic saline is used for routine tracheostomy site cleansing to reduce infection risk.

C. Change the client's tracheostomy ties every 72 hr.
Ties should be changed as needed or per protocol, often more frequently in early post-op period.

D. Suction the client's tracheostomy every 6 hr.
Suction as needed, not on a fixed schedule, to avoid mucosal trauma.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the admission of a client who is scheduled for surgery. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is contributing to the plan of care for a client who had a tracheostomy placed 2 hr ago. Which of the following interventions should the nurse recommend for the plan of care?

Correct Answer is B

Explanation

A nurse is collecting data from a client who is recovering from a recent stroke. Which of the following findings should indicate to the nurse the need for a referral to a speech-language pathologist?

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