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 B
Explanation
Choice A rationale:
Placing the client on seizure precautions is not the appropriate action in this scenario. Shaking chills during the immediate postpartum period are not indicative of a seizure. Seizure precautions involve measures like protecting the client from injury during a seizure, such as moving them to a safe area and providing a padded bed or mattress. This is not relevant to the client's current situation of shaking chills.
Choice C rationale:
Covering the client with warm blankets may provide comfort and help raise body temperature if the client is experiencing chills due to being cold. However, it does not address the underlying cause of the shaking chills. The nurse should first assess the client's temperature to determine the cause of the chills before implementing interventions.
Choice D rationale:
Notifying the charge nurse is not the immediate action needed when a client is experiencing shaking chills. The primary responsibility of the nurse in this situation is to assess and identify the cause of the chills. Once the cause is determined, appropriate interventions can be initiated. It's essential to focus on the immediate assessment of the client's condition.
Correct Answer is B
Explanation
The correct answer is choice b. Drying the newborn’s skin thoroughly.
Choice A rationale:
Maintaining ambient room temperature at 24° C (75° F) helps in reducing overall heat loss but does not specifically address evaporative heat loss. Evaporative heat loss occurs when moisture on the skin evaporates, cooling the skin.
Choice B rationale:
Drying the newborn’s skin thoroughly reduces evaporative heat loss by removing moisture that can evaporate and cool the skin. This is a critical action immediately after birth when the newborn is wet with amniotic fluid.
Choice C rationale:
Preventing air drafts helps reduce convective heat loss, not evaporative heat loss. Convective heat loss occurs when air currents carry heat away from the body.
Choice D rationale:
Placing the newborn on a warm surface helps reduce conductive heat loss, which occurs when the newborn’s body comes into contact with a cooler surface. This does not specifically address evaporative heat loss.
By thoroughly drying the newborn’s skin, the nurse effectively minimizes evaporative heat loss, ensuring the newborn maintains a stable body temperature.
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