A woman who delivered a normal newborn 24 hours ago reports, "I seem to be urinating every hour or so. Is that OK?”. Which action should the practical nurse (PN) implement?

Catheterize the client for residual urine volume.

Evaluate for normal involution, then massage the fundus.

Measure the next voiding, then palpate the client's bladder.

Obtain a specimen for urine culture and sensitivity.

Answer and Explanation

The Correct Answer is C

Correct Answer: C. Measure the next voiding, then palpate the client's bladder.

Choice A rationale:

Catheterizing the client for residual urine volume is not necessary at this point because the woman has recently given birth, and frequent urination is common during the postpartum period. Additionally, catheterization poses risks of infection, so it should be reserved for situations where it is clinically indicated.

Choice B rationale:

Evaluating for normal involution and massaging the fundus is not relevant in this context. Fundal massage is performed after childbirth to ensure the uterus contracts and prevents excessive bleeding. The woman's concern is about frequent urination, which does not require fundal massage.

Choice C rationale:

Measuring the next voiding and palpating the client's bladder is the most appropriate action. The woman's increased frequency of urination could be due to postpartum diuresis, a normal physiological process where the body eliminates excess fluid accumulated during pregnancy. By measuring the next voiding and palpating the bladder, the nurse can assess for bladder distension or retention, which could be signs of a problem.

Choice D rationale:

Obtaining a specimen for urine culture and sensitivity is not indicated in this situation. There is no evidence to suggest that the woman has a urinary tract infection or other urinary issues that would warrant a urine culture at this time.

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Correct Answer is D

Explanation

This is the best action that describes the responsibility of the PN because it ensures that the client has given informed consent for the invasive examination and that the consent form is valid and documented. The PN should verify that the provider has explained the examination, its risks and benefits, and alternative options to the client and that the client has agreed to proceed.

A. Explaining the examination and asking the client to sign the consent form is not the responsibility of the PN but of the provider who will perform the examination.

B. Obtaining the medical record for the correct signed consent form prior to the examination is not enough to ensure informed consent and may not involve any interaction with the client.

C. Asking if the client understands the exam and why the consent form must be signed is not enough to ensure informed consent and may not address any questions or concerns that the client may have.

A. Instruct an unlicensed assistive personnel (UAP) to stay with the client. B. Notify the client's healthcare provider C. Administer an as needed (PRN) medication for agitation D. Escort the client to a calm and quiet place.

Correct Answer is D

Explanation

d. Escort the client to a calm and quiet place.

The PN should use a calm and firm approach to de-escalate the situation and remove the client from the stressful environment. This can help prevent further agitation and potential violence.

The other options are not correct because:

Instructing a UAP to stay with the client may not be eﬀective or safe, as the UAP may not have the skills or training to handle an agitated client.
Notifying the client's healthcare provider is not a priority action, as it does not address the immediate safety of the client and others.
Administering a PRN medication for agitation may be indicated, but it is not the first action. The PN should try non- pharmacological interventions first, unless there is an imminent risk of harm.

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A woman who delivered a normal newborn 24 hours ago reports, "I seem to be urinating every hour or so. Is that OK?”. Which action should the practical nurse (PN) implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Prior to an invasive examination of a hospitalized client, a consent form should be obtained. Which action best describes the responsibility of the practical nurse (PN)?

Correct Answer is D

Explanation

A client in the psychiatric unit's dayroom is becoming agitated, talking incessantly, and starting to yell and swear at the other clients. Which action should the practical nurse (PN) implement first?

Correct Answer is D

Explanation

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