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","B","D"]
Explanation
D.
Choice A rationale
Initiation of peripheral IV access is a common procedure in the emergency department for patients who have experienced a fall. This allows for the administration of fluids and medications as needed.
Choice B rationale
An X-ray of the left shoulder and right knee would likely be ordered given the patient’s report of pain in his left shoulder after the fall. This would help to identify any fractures or other injuries.
Choice C rationale
A CT scan of the brain may not be necessary in this case, unless the patient was experiencing symptoms such as confusion, loss of consciousness, or other neurological signs following the fall.
Choice D rationale
Administration of pain medication would likely be initiated based on the patient’s report of pain.
Correct Answer is B
Explanation
Choice A rationale
While placing a certified copy of the living will in the patient’s record is important, it is not the immediate next step. The living will should be acknowledged, but the healthcare provider needs to be informed immediately.
Choice B rationale
Informing the healthcare provider of the patient’s wishes is the most appropriate next step. The healthcare provider can then make decisions based on the patient’s expressed wishes.
Choice C rationale
Arranging a family meeting with the palliative care team may be beneficial, but it is not the immediate next step. The healthcare provider needs to be informed first.
Choice D rationale
Notifying the nursing staff of the patient’s do not resuscitate status is important, but it is not the immediate next step. The healthcare provider needs to be informed first.
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