A nurse is caring for a client who is postpartum and reports difficulty voiding. Which of the following findings should indicate to the nurse that the client's ability to eliminate urine from the bladder is restored?

Fundus 2 fingerbreadths above the umbilicus

Uterine atony

Fundus firm and to the right of the abdominal midline

Two voids of 150 mL each over the past 2 hr

Answer and Explanation

The Correct Answer is D

A. Fundus 2 fingerbreadths above the umbilicus: This finding relates to uterine involution rather than urinary elimination. While important for postpartum assessment, it does not indicate restored bladder function.

B. Uterine atony: Uterine atony is a complication that increases the risk of postpartum hemorrhage. It does not provide information about the client’s ability to void and requires separate monitoring and intervention.

C. Fundus firm and to the right of the abdominal midline: A firm but displaced fundus may indicate a full bladder, which can interfere with urination. This finding suggests bladder distention rather than restored urinary elimination.

D. Two voids of 150 mL each over the past 2 hr: Adequate urine output in regular intervals indicates that the bladder is emptying effectively. Measuring volume and frequency confirms the client’s ability to eliminate urine has been restored postpartum.

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Correct Answer is D

Explanation

A. Make referrals to support services: Referrals to social, medical, or mental health support are part of the response and recovery phases, focusing on addressing ongoing client needs after the disaster occurs, rather than planning.

B. Coordinate care in shelters: Coordinating care in shelters is an activity performed during the response phase, when the disaster has already occurred and immediate client needs must be addressed. It is not part of pre-event planning.

C. Triage injured individuals: Triage occurs during the response phase to prioritize treatment based on injury severity. This action is reactive to actual casualties and is not part of the planning phase.

D. Participate in practice drills: Engaging in disaster preparedness drills is a key component of the planning phase. Drills help identify gaps in emergency protocols, improve staff readiness, and ensure effective coordination during an actual mass casualty incident.

A. Prepare for chest tube placement. B. Ensure that the client has venous access. C. Place the client in High Fowler's position. D. Activate the rapid response team. E. Administer fondaparinux as prescribed. F. Administer midazolam as prescribed.

Correct Answer is ["B","C","D","E"]

Explanation

A. Prepare for chest tube placement: Chest tube placement is indicated for conditions like pneumothorax or pleural effusion, which are not clearly present in this scenario. Immediate interventions should focus on stabilizing the client and evaluating cardiopulmonary status first.

B. Ensure that the client has venous access: Establishing IV access is essential for rapid administration of medications, fluids, or emergency interventions if the client’s condition deteriorates. This is a priority in acute postoperative complications.

C. Place the client in High Fowler's position: Elevating the head of the bed improves lung expansion, reduces dyspnea, and enhances oxygenation in a client experiencing sudden respiratory distress and crackles, which may indicate pulmonary edema or fluid overload.

D. Activate the rapid response team: The client exhibits acute respiratory distress, hypoxemia, tachypnea, and cardiovascular changes. Activating the rapid response team ensures timely advanced intervention and evaluation to prevent further deterioration.

E. Administer fondaparinux as prescribed: Postoperative clients following total hip arthroplasty are at high risk for venous thromboembolism. Administering anticoagulant therapy, such as fondaparinux, helps prevent pulmonary embolism, which could be causing the client’s sudden dyspnea.

F. Administer midazolam as prescribed: Midazolam is a sedative and would not address the client’s acute respiratory distress. Sedation could worsen hypoxemia and respiratory compromise in this scenario.

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A nurse is caring for a client who is postpartum and reports difficulty voiding. Which of the following findings should indicate to the nurse that the client's ability to eliminate urine from the bladder is restored?

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Naxlex Comprehensive Predictor Exams

A public health nurse is preparing for a mass casualty incident. Which of the following tasks should the nurse complete during the planning phase of disaster management?

Correct Answer is D

Explanation

The nurse is caring for a client. Which of the following actions should the nurse take? Select all that apply.

Correct Answer is ["B","C","D","E"]

Explanation

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