A nurse is receiving report about assigned clients at the start of his shift.
Which of the following clients should the nurse plan to attend to first?
A client who is scheduled for discharge in 2 hr following a laparoscopic tubal ligation.
A client who experienced a cesarean birth 4 hr ago and reports pain.
A client who has preeclampsia and a BP of 138/90 mm Hg.
A client who experienced a vaginal birth 24 hr ago and reports no bleeding.
The Correct Answer is B
Choice A rationale:
The nurse should prioritize the client's needs based on the severity of their condition. A client scheduled for discharge in 2 hours following a laparoscopic tubal ligation is generally stable and not in immediate need of care. Discharge planning can be done later.
Choice B rationale:
A client who experienced a cesarean birth 4 hours ago and reports pain requires immediate attention. Pain is a subjective symptom that should be addressed promptly to ensure the client's comfort and well-being. Uncontrolled pain can lead to complications and negatively affect the client's overall recovery.
Choice C rationale:
A client with preeclampsia and a blood pressure of 138/90 mm Hg is a concerning situation, but it is not the top priority in this scenario. Preeclampsia requires monitoring and intervention, but the client who just had a cesarean birth and is experiencing pain should be attended to first.
Choice D rationale:
A client who experienced a vaginal birth 24 hours ago and reports no bleeding is not a high-priority concern. Some clients may have minimal bleeding or none at all after a vaginal birth, and this can be normal. The absence of bleeding alone does not warrant immediate attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Answer and explanation
A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft; fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7°C (100°F); pulse rate 88/min; respiratory rate 18/min. Which of the following actions should the nurse perform? The correct answer is Choice A: Report the client's temperature elevation.
Choice A rationale:
The nurse should report the client's temperature elevation because a temperature of 37.7°C (100°F) is above the normal range for a postpartum client. A postpartum temperature greater than 100.4°F (38°C) may indicate an infection, such as endometritis or mastitis. It is essential to identify and treat infections promptly to prevent complications.
Choice B rationale:
Asking the client to empty her bladder is not the most appropriate action in this situation. While bladder distention can sometimes cause uterine displacement, the elevated temperature is a more urgent concern. The nurse should address the temperature issue first.
Choice C rationale:
Increasing IV fluids is not indicated based on the information provided. The client's temperature elevation and soft breasts are concerning, and increasing IV fluids will not address these issues. It's essential to focus on the potential infection first.
Choice D rationale:
Encouraging the client to nurse more frequently to stimulate milk production is not the priority in this scenario. While breastfeeding is essential for milk production and uterine involution, the client's elevated temperature and other findings should be addressed first.
Correct Answer is A
Explanation
Choice A rationale:
The client is experiencing symptoms that suggest hyperventilation due to paced breathing, which can lead to respiratory alkalosis. Breathing into a paper bag or cupped hand allows the client to rebreathe carbon dioxide and helps correct the alkalosis by increasing the carbon dioxide levels in the blood. This is a common intervention for clients experiencing lightheadedness and tingling in the fingers due to hyperventilation.
Choice B rationale:
Instructing the client to maintain a breathing rate no less than twice the normal rate is not appropriate in this situation. It can worsen the client's symptoms and may lead to further hyperventilation. This choice does not address the underlying problem of respiratory alkalosis.
Choice C rationale:
Having the client tuck her chin to her chest is not the correct action for these symptoms. This maneuver is typically used to relieve supraventricular tachycardia (SVT) or vagal stimulation in situations of rapid heart rate. It is not relevant to the client's lightheadedness and tingling fingers.
Choice D rationale:
Administering oxygen via nasal cannula is not indicated in this case. The client's symptoms are not suggestive of hypoxemia, but rather, they are related to respiratory alkalosis. Providing oxygen could potentially worsen the condition by reducing carbon dioxide levels further.
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