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Exhibits

Based on the assessment data, the nurse recognizes the need to intervene immediately.

Select the 5 priority interventions that the nurse should initiate based on the most recent assessment.

Notify primary healthcare provider

Count saturated pads per hour

Administer 2 units of packed red blood cells (PRBC)

Administer 0.2 mg methylergonovine IM

Insert straight catheter

Alert the emergency response team

Increase the IV fluid to maximum rate

Weigh all bloody materials

Massage fundus until firm

Answer and Explanation

Correct Answer : A,B,D,F,G,I

A.Notify primary healthcare provider
The client's vital signs indicate signs of potential hypovolemic shock (low blood pressure, tachycardia, fever), and the saturated pad and sheets suggest ongoing significant bleeding. Notifying the primary healthcare provider is crucial to obtain further orders and potentially escalate care.
B.   Count saturated pads per hour
Counting saturated pads per hour provides a quantitative assessment of blood loss and helps monitor the effectiveness of interventions aimed at reducing bleeding. This ongoing assessment guides further management decisions.
C.   Administer 2 units of packed red blood cells (PRBC)

While blood loss is significant, initiating a blood transfusion is not typically an immediate first-line intervention unless the client shows signs of severe hemorrhagic shock or ongoing bleeding that cannot be controlled by other measures.
D.   Administer 0.2 mg methylergonovine IM
Methylergonovine is a medication used to promote uterine contraction and control postpartum hemorrhage. Given the boggy fundus and significant bleeding, administering methylergonovine IM helps to contract the uterus and reduce bleeding.
E.   Insert straight catheter
While maintaining accurate fluid balance is important, inserting a straight catheter is not an immediate priority compared to addressing active hemorrhage and stabilizing the client's condition.
F.   Alert the emergency response team
The client's condition, with a boggy fundus, saturated pads, and ongoing bleeding, indicates a need for urgent intervention beyond routine measures. Alerting the emergency response team ensures prompt assistance and resources for managing potential hemorrhagic shock.
G.   Increase the IV fluid to maximum rate
Increasing IV fluid administration helps to restore circulating volume and stabilize the client's blood pressure. This is essential in managing hypovolemia resulting from significant postpartum hemorrhage.
H.   Weigh all bloody materials
Weighing all bloody materials is a method to estimate blood loss but is not as urgent as direct interventions aimed at stopping bleeding and stabilizing the client.
I.   Massage fundus until firm
Massaging the fundus helps to stimulate uterine contractions, which can help control bleeding by compressing blood vessels at the placental site. A boggy fundus indicates poor uterine tone, and firming it up is crucial to prevent further hemorrhage.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Rationale

A. During a thoracentesis, a needle is inserted through the chest wall into the pleural space to remove fluid or air. It's common for clients to feel a stinging sensation or discomfort during needle insertion. The nurse should confirm this understanding with the client and reassure them that local anesthesia will be used to minimize discomfort.

B. The positioning described (sitting forward with arms propped on a table) helps to expand the intercostal spaces and facilitates easier access to the pleural space during the procedure. The nurse should reinforce this position as appropriate for the thoracentesis procedure.

C. This statement is incorrect and would indicate a need for additional education. A persistent cough is not an expected outcome after a thoracentesis. While some clients may experience a mild cough during or immediately after the procedure due to irritation from the needle or local anesthesia, it should not persist afterwards.

D. This statement is generally correct. After a thoracentesis, it is recommended to limit strenuous activity and avoid heavy lifting for a day or two to minimize the risk of complications such as discomfort or injury at the needle insertion site. The nurse should support this instruction as part of the client's post-procedure care.

A. Activation of complement pathways. B. Inhibition of red blood production. C. Production of extra platelets. D. Depletion of clotting factors.

Correct Answer is D

Explanation

Rationale

A. The complement system is part of the immune response and can be activated in various conditions, including sepsis. However, activation of complement pathways does not directly cause DIC. Instead, in septic shock, the release of pro-inflammatory cytokines and tissue factor can trigger systemic coagulation activation, leading to DIC.

B. Inhibition of red blood cell production, such as in conditions like aplastic anemia or certain types of bone marrow disorders, does not directly cause DIC. DIC is primarily a disorder of excessive activation of clotting factors in response to underlying conditions like sepsis, trauma, or cancer.

C. Production of extra platelets, or thrombocytosis, is not the cause of DIC. Thrombocytosis can occur in response to various conditions, but DIC involves consumption of platelets due to widespread activation of clotting within the vasculature.

D. DIC is characterized by the widespread consumption and depletion of clotting factors and platelets as they are used up in the formation of microthrombi throughout the bloodstream. This depletion leads to an increased risk of bleeding due to insufficient clotting factors remaining to maintain hemostasis.

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Exhibits Based on the assessment data, the nurse recognizes the need to intervene immediately. Select the 5 priority interventions that the nurse should initiate based on the most recent assessment.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing a client for an outpatient thoracentesis. Which statement made by the client should the nurse recognize as needing additional education?

Correct Answer is C

Explanation

A client with septic shock develops disseminated intravascular coagulation (DIC). Which pathophysiologic process should the nurse recognize as the cause of the coagulation problem?

Correct Answer is D

Explanation

A client receives a prescription for 1 L of lactated Ringer's IV to be infused over 12 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection indicates to the nurse that the client understands the prescribed diet? A Baked potato with skin, raw carrots.

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? Select all that apply.

The charge nurse observes a new nurse preparing to irrigate an intravenous catheter. The new nurse brought a luer-lock tipped syringe. Which action should the charge nurse take?

A client is admitted to the intensive care until (ICU) with a spinal cord injury following a motor vehicle collision. Which nurse should be contacted to coordinate the progression of the client's care?

Exhibits

Based on the assessment data, the nurse recognizes the need to intervene immediately.

Select the 5 priority interventions that the nurse should initiate based on the most recent assessment.