A straight catheter produced 500 mL of clear yellow urine.
For each finding, indicate whether the findings suggest that the client’s condition has improved or put the client at risk for hypovolemia.
Each column must have at least one selection.
Total blood loss of 800 mL
Fundus massaged until firm and at umbilicus
Multiple large clots were expelled
Blood pressure of 110/80 mm Hg, heart rate of 66 beats/minute, oxygen saturation at 98% on room air .
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}
The findings suggest that the client’s condition has improved.
Choice A rationale
A total blood loss of 800 mL is a significant amount, but it is within the normal range for blood loss during and after childbirth. Therefore, this does not necessarily put the client at risk for hypovolemia.
Choice B rationale
A fundus that is firm and at the level of the umbilicus indicates that the uterus is contracting properly after childbirth, which helps to prevent excessive bleeding.
Choice C rationale
The expulsion of multiple large clots could indicate that the body is effectively clotting blood, which can prevent excessive bleeding.
Choice D rationale
A blood pressure of 110/80 mm Hg, a heart rate of 66 beats/minute, and an oxygen saturation of 98% on room air are all within normal ranges, indicating that the client is stable and not at risk for hypovolemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"}}
Explanation
Based on the questionand the known effects of furosemide, here’s how each assessment finding can be categorized:
- Potassium 3.1 mEq/L: This is anon-therapeutic side effect.Furosemide is a diuretic that increases the excretion of water, sodium, and potassium from the body.This can lead to hypokalemia, or low potassium levels.
- Prothrombin time/INR 2.2: This is likely anunrelated finding.Furosemide does not typically affect prothrombin time or INR.However, the patient is also taking warfarin, which is an anticoagulant known to increase INR.
- Urine output: 600 mL: This is atherapeutic result.Furosemide works by increasing the amount of urine the body makes, which helps reduce swelling and symptoms of fluid retention.
Correct Answer is B
Explanation
Choice A rationale
While advising family members to monitor for symptoms of illness is important, it’s not the most crucial action for the nurse to take immediately after testing the patient for COVID-194.
Choice B rationale
Implementing droplet precautions, placing the patient in a private room, and keeping the door closed is the most crucial action. This helps prevent the potential spread of COVID-19 to other patients and healthcare workers.
Choice C rationale
Informing the patient to notify others about potential exposure is important, but it’s not the most crucial action immediately after testing.
Choice D rationale
Initiating an IV infusion for the administration of an antiviral drug is not the most crucial action. Antiviral medication is typically administered after a positive test result, not before.
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