A nurse is caring for a client who is 4 days postpartum following a cesarean birth

Exhibits

For each potential assessment finding, click to specify if the assessment finding is consistent with mastitis or endometritis. Each finding may support more than 1 disease process

Painful, tender breast

Temperature

Chills

Foul-smelling lochia

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"B"}}

Mastitis: A, B, C

Endometritis: B, C, D

Rationale:
A.   This finding is consistent with mastitis. Mastitis is characterized by inflammation of the breast tissue, often presenting with pain, tenderness, warmth, and redness in the affected breast.
B.   This finding can be indicative of both mastitis and endometritis. A fever, as indicated by an elevated temperature (38.8°C or 101.9°F), is a common symptom of both mastitis and endometritis. It suggests an inflammatory response or infection in the body.
C.   This finding is also consistent with both mastitis and endometritis. Chills often accompany fever and can be a sign of systemic infection or inflammation.
D.   This finding is more indicative of endometritis. Endometritis involves infection or inflammation of the uterine lining, which can result in foul-smelling lochia. Foul- smelling lochia may indicate the presence of infection within the uterus.

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Correct Answer is A

Explanation

A. Documenting the transfusion reaction in the medical record is essential for accurate documentation and communication among the healthcare team.
B. Administering epinephrine subcutaneously is not indicated for febrile transfusion reactions. It is instead indicated for anaphylaxis.
C. Infusing lactated Ringer's IV may be indicated for managing transfusion reactions, but the specific treatment depends on the type and severity of the reaction. It's essential to consult with the healthcare provider for appropriate interventions.
D. Placing the blood bag in a biohazard bag before discarding is a routine procedure for disposing of blood products but is not the immediate priority when managing a transfusion reaction.

A. Give the dose over 60 min. B. Administer the medication undiluted. C. Inject 19% lidocaine prior to each dose. D. Obtain a trough level 30 min after the medication infusion.

Correct Answer is A

Explanation

A. Administering vancomycin over a longer infusion time, such as 60 minutes, can help reduce the risk of adverse reactions, such as red man syndrome or nephrotoxicity. Slower infusion rates allow for better tolerance of the medication.
B. Vancomycin should be diluted appropriately before administration to reduce the risk of infusion-related reactions.
C. Lidocaine is not typically used prior to vancomycin administration. The use of lidocaine would be more relevant for local anesthesia, not for systemic medication administration like vancomycin.

D. Trough levels are typically obtained just before the next dose of vancomycin is due, not immediately after the infusion.

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A nurse is caring for a client who is 4 days postpartum following a cesarean birth Exhibits For each potential assessment finding, click to specify if the assessment finding is consistent with mastitis or endometritis. Each finding may support more than 1 disease process

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a prescription for 1 unit of packed RBCs. Five minutes after beginning the transfusion, the client becomes febrile with chills. After stopping the transfusion, which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is planning to administer vancomycin IV to a client. Which of the following actions should the nurse take to reduce the risk of an adverse reaction to the vancomycin?

Correct Answer is A

Explanation

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A nurse is caring for a client who is 4 days postpartum following a cesarean birth

Exhibits

For each potential assessment finding, click to specify if the assessment finding is consistent with mastitis or endometritis. Each finding may support more than 1 disease process