A nurse is caring for a client.

Exhibits

The nurse is caring for a client on the postpartum unit.

The nurse is caring for the client following an emergency cesarean birth. Which of the following findings indicate an improvement in the client's condition?

Select all that apply.

Hemoglobin

Heart rate

Pain level

Temperature

Vaginal bleeding

Blood pressure

Answer and Explanation

Correct Answer : B,C,E,F

A. Hemoglobin: Although an improvement in hemoglobin would be ideal, it may take more time to see a significant change after blood loss or transfusion. A rise in hemoglobin indicates that the body is recovering from blood loss, but it is not as immediate an indicator of improvement as other factors, such as heart rate or blood pressure stabilization.

B. Heart rate: A decrease in the heart rate toward the normal range (60-100 beats/min) indicates improvement in the client's condition. The initial heart rate of 120-128 beats/min (tachycardia) suggests the client may have been compensating for blood loss or pain. A more stable heart rate would suggest a response to treatment and improvement in their cardiovascular status.

C. Pain level: A reduction in pain score is an important indicator of recovery post-surgery. After an emergency cesarean birth, pain management is a critical aspect of recovery, and a reduction in pain intensity would suggest that the client is improving and responding well to pain management interventions.

D. Temperature: A normal temperature would suggest no infection or complications. However, temperature changes in the immediate postpartum period can be influenced by various factors (e.g., infection, hormonal changes, or recovery from surgery). It is not as immediate an indicator of recovery as heart rate or blood pressure.

E. Vaginal bleeding: A decrease in vaginal bleeding, especially after a cesarean, would indicate that bleeding is being effectively controlled and the uterus is contracting appropriately, reducing the risk of hemorrhage or complications like uterine atony.

F. Blood pressure: A return to normal blood pressure levels (e.g., closer to the pre-pregnancy baseline) would indicate that the client's circulatory status is stabilizing. The dropping blood pressure seen earlier (from 95/62 mm Hg to 85/48 mm Hg) indicated hypovolemic shock or a response to blood loss, so stabilization and an increase in blood pressure would be a positive sign.

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Correct Answer is D

Explanation

A. Schedule the client for retesting in 1 week: Retesting is typically done after 3 months, not 1 week.

B. Administer ceftriaxone via intermittent IV bolus: Ceftriaxone is used for gonorrhea, not chlamydia.

C. Instruct the client to abstain from sexual intercourse for 1 month: Abstinence is recommended until treatment is completed and partners are treated, not necessarily for 1 month.

D. Report the infection to the state department of health: Reporting is required by law to help track and reduce the spread of STIs.

A. Protect the IV bag from exposure to light. B. Keep calcium gluconate at the client's bedside. C. Attach an inline filter to the IV tubing. D. Monitor blood pressure every 2 hr.

Correct Answer is A

Explanation

A. Protect the IV bag from exposure to light: Nitroprusside is light-sensitive and degrades when exposed to light, reducing its potency and effectiveness. It must be protected with an opaque covering.

B. Keep calcium gluconate at the client’s bedside: Incorrect. Calcium gluconate is used to treat hyperkalemia or calcium imbalances, not for nitroprusside administration.

C. Attach an inline filter to the IV tubing: Incorrect. An inline filter is not typically required for nitroprusside.

D. Monitor blood pressure every 2 hr: Incorrect. Continuous or frequent monitoring (every 5-15 minutes) is necessary due to the rapid effects of nitroprusside on blood pressure.

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A nurse is caring for a client. Exhibits The nurse is caring for a client on the postpartum unit. The nurse is caring for the client following an emergency cesarean birth. Which of the following findings indicate an improvement in the client's condition? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a new diagnosis of Chlamydia trachomatis. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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A nurse is caring for a client.

Exhibits

The nurse is caring for a client on the postpartum unit.

The nurse is caring for the client following an emergency cesarean birth. Which of the following findings indicate an improvement in the client's condition?

Select all that apply.