Exhibits
The nurse is reviewing the chart. select the condition from the choices below to fill in each blank in the following sentence. Based on the client's history and physical, the nurse notes that this postpartum client is most at risk for developing
The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
This client is at risk for VTE due to several factors, including being postpartum, prolonged labor (25 hours), and potential immobility after delivery. Additionally, the presence of a 4th-degree laceration may lead to decreased mobility, increasing the risk of blood clots.
Wound Dehiscence:
The client has a 4th-degree laceration, which involves a significant degree of tissue damage and may require careful monitoring for proper healing. Factors such as infection (noted by slight fever), tension on the wound, or inadequate healing can contribute to the risk of dehiscence.-
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","F"]
Explanation
A. Clenched fists can indicate discomfort or pain in infants, suggesting the need for pain management.
B. Restlessness is often a sign of pain or discomfort in infants and requires assessment for pain relief.
C. Peripheral pallor can indicate other issues such as shock or anemia but is not a direct indicator of pain.
D. An increased respiratory rate can be a response to pain or distress, indicating the child may need pain medication.
E. An increased temperature could indicate infection or inflammation, but it is not a direct indicator of pain requiring medication.
F. An increased pulse rate may indicate pain or anxiety and should be considered in the context of the child's overall assessment.
Correct Answer is ["C","D","E","F"]
Explanation
A. Have an opioid agonist at the bedside is not necessary because clonazepam is a benzodiazepine, and its administration does not typically require an opioid agonist as a safety measure. This choice is not relevant to clonazepam.
B. Monitoring calcium levels is not a standard nursing intervention for a patient starting clonazepam. This medication does not typically affect calcium levels.
C. Clonazepam can cause dry mouth, making good oral hygiene important to prevent complications such as dental caries or oral infections. Regular oral care helps maintain oral health.
D. Clonazepam can cause sedation and dizziness, increasing the risk of falls. Assisting the client to the bathroom helps ensure their safety while they may be adjusting to the medication.
E. Benzodiazepines, including clonazepam, can cause sedation and dizziness, leading to orthostatic hypotension. Monitoring for this condition is important to prevent falls and ensure the client’s safety.
F. Regular assessment of mental status is crucial as clonazepam can cause drowsiness, confusion, or cognitive impairment, especially in older adults. Monitoring helps detect any adverse effects early on.
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