A nurse is providing care for a group of postpartum clients. Which of the following clients should the nurse see first?

A client who is 4 hr postpartum and has a heart rate of 90/min

A client who is 4 days postpartum and has a WBC count of 18,000/mm3 (5,000 to 10,000/mm3)

A client who is 12 hr postpartum and has an oral temperature of 37.8° C (100° F)

A client who is 2 days postpartum and reports dysuria

Answer and Explanation

The Correct Answer is B

Rationale:

A. A client who is 4 hr postpartum and has a heart rate of 90/min: A heart rate of 90/min is within normal postpartum limits. This client is stable and does not require immediate assessment, making them a lower priority compared to clients showing signs of possible infection or complications.

B. A client who is 4 days postpartum and has a WBC count of 18,000/mm³ (5,000 to 10,000/mm³): An elevated WBC count 4 days postpartum can indicate a serious infection, such as endometritis or another postpartum infection. This client is at risk for rapid deterioration and requires immediate assessment and intervention.

C. A client who is 12 hr postpartum and has an oral temperature of 37.8° C (100° F): A mild temperature elevation shortly after birth can be expected due to normal postpartum physiologic changes. While it should be monitored, it is not as urgent as the markedly elevated WBC count indicating potential infection.

D. A client who is 2 days postpartum and reports dysuria: Dysuria may indicate a urinary tract infection, which requires evaluation, but this is less immediately threatening than a client with signs of systemic infection. This client should be assessed after clients with potential severe infection or hemodynamic instability.

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Correct Answer is D

Explanation

Rationale:

A. "Why did you start drinking alcohol?": This question explores motivations or personal history but is not part of the standardized Alcohol Use Disorders Identification Test (AUDIT). The AUDIT focuses on quantity, frequency, and consequences of alcohol use rather than reasons for drinking.

B. "Does anyone else in your family have a drinking problem?": Family history of alcohol use may be relevant for overall assessment but is not included in the AUDIT, which is designed to screen the client’s own drinking behaviors and risks.

C. "How old were you when you started to drink alcohol?": Age of initiation provides background information but is not a question within the AUDIT. The test is concerned with current patterns and consequences of alcohol consumption.

D. "How often do you drink alcohol?": This question is a standard component of the AUDIT and assesses the frequency of alcohol consumption. It helps identify patterns of use and potential risk for alcohol-related problems, making it appropriate for inclusion in the screening.

A. Remove the cap and place it sterile-side up on a clean surface. B. Hold the bottle in the center of the sterile field when pouring the solution C. Place sterile gauze over areas of spilled solution within the sterile field. D. Hold the irrigation solution bottle with the label facing away from the palm of the hand

Correct Answer is A

Explanation

A. Placing the cap sterile-side up on a clean surface prevents contamination of the inside of the cap and maintains the sterility of the solution. This step is essential before pouring to ensure the solution remains sterile.

B. Holding the bottle in the center of the sterile field risks contaminating the field if solution drips; the bottle should be held above or beside the field, not directly over it.

C. Placing sterile gauze over spilled solution does not restore sterility; contaminated areas must be replaced or discarded.

D. Holding the bottle with the label facing away from the palm helps protect the label, but it does not directly affect the sterility of the solution during pouring.

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A nurse is providing care for a group of postpartum clients. Which of the following clients should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to perform an Alcohol Use Disorders identification Test with a client. Which of the following questions should the nurse Include?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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