Exhibits

The nurse is reviewing the client's chart.

For each finding, click to indicate whether 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.

Fundus massaged until firm and at umbilicus

Multiple large clots were expelled

Straight catheter produced 500 mL clear yellow urine

Total blood loss of 800 mL

Blood pressure of 110/80 mm Hg, heart rate of 66 beats/minute, oxygen saturation at 98% on room air

200 mL blood loss

Fundus remains firm with slight lochia noted on pad

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"B"}}

At risk of hypovolemia

D. Total blood loss of 800 mL

A total blood loss of 800 mL indicates significant hemorrhage, which puts the client at risk for hypovolemia (low blood volume). While exact definitions may vary, typically, blood loss exceeding 500 mL postpartum is considered significant and increases the risk of hypovolemia if not managed appropriately.

F. 200 mL blood loss

While 200 mL of blood loss is within the normal range for immediate postpartum period, it still represents a loss of blood that, if ongoing, could potentially lead to hypovolemia if not monitored closely.

Condition has improved

A. Fundus massaged until firm and at umbilicus

Massaging the fundus until it is firm and at the umbilicus helps ensure uterine contraction, which reduces the risk of excessive bleeding and promotes hemostasis. This indicates that uterine tone is adequate, which is a positive sign.

C. Straight catheter produced 500 mL clear yellow urine

The passage of 500 mL of clear yellow urine indicates adequate renal perfusion and hydration status, suggesting that the client's fluid balance is being maintained or improved, which is important in preventing hypovolemia.

E. Blood pressure of 110/80 mm Hg, heart rate of 66 beats/minute, oxygen saturation at 98% on room air

Stable vital signs with normal blood pressure, heart rate, and oxygen saturation indicate adequate perfusion and oxygenation. This suggests that the client's condition is stable and not immediately at risk for hypovolemia.

G. Fundus remains firm with slight lochia noted on pad

A firm fundus with slight lochia (postpartum vaginal discharge) indicates ongoing normal involution (shrinking) of the uterus with minimal bleeding. This suggests that the client's uterus is contracting well, which is favorable for preventing hypovolemia.

Nursing Test Bank

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Correct Answer is B

Explanation

Rationale

A. Nausea and headache are common side effects of linezolid. While they can impact the client's comfort and adherence to treatment, they are generally not considered urgent or life-threatening unless severe or persistent.

B. Watery diarrhea is a significant concern with linezolid therapy, as it can indicate the development of Clostridium difficile infection (CDI) or other types of antibiotic-associated diarrhea. CDI is a severe condition that requires prompt treatment to prevent complications such as dehydration, colitis, and potentially life-threatening outcomes like toxic megacolon.

C. Increased fatigue can be a nonspecific symptom and may result from various factors, including the underlying illness (nosocomial pneumonia), medication side effects, or the stress of hospitalization. While it should be monitored, it is typically not an immediate concern unless accompanied by other concerning symptoms.

D. Yellow-tinged sputum can indicate the presence of infection or inflammation in the respiratory tract, which is relevant in the context of nosocomial pneumonia. It could suggest a worsening of the pneumonia or a new infection. However, it is not typically directly associated with linezolid therapy itself.

A. Green leafy vegetables. B. Fresh fruits. C. Yogurt or buttermilk. D. Avocados and cheese.

Correct Answer is C

Explanation

Rationale

A. Green leafy vegetables do not interact with cefdinir. They are generally a healthy choice and can be encouraged without any concerns related to the antibiotic therapy.

B. Fresh fruits are also safe to consume with cefdinir. There are no interactions between fruits and this antibiotic.

C. Yogurt and buttermilk contain probiotics, which are beneficial bacteria that can help maintain gut health. Antibiotics like cefdinir can disrupt the normal gut flora, leading to diarrhea or other gastrointestinal issues. Consuming yogurt or buttermilk with live cultures may help replenish beneficial bacteria in the gut and reduce the risk of antibiotic-associated diarrhea.

D. Avocados and cheese are also safe choices. There are no specific interactions between these foods and cefdinir.

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Exhibits The nurse is reviewing the client's chart. For each finding, click to indicate whether 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.

D. Total blood loss of 800 mL

F. 200 mL blood loss

A. Fundus massaged until firm and at umbilicus

C. Straight catheter produced 500 mL clear yellow urine

E. Blood pressure of 110/80 mm Hg, heart rate of 66 beats/minute, oxygen saturation at 98% on room air

G. Fundus remains firm with slight lochia noted on pad

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

Correct Answer is B

Explanation

The healthcare provider prescribes the antibiotic cefdinir 300 mg PO every 12 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat?

Correct Answer is C

Explanation

The nurse is teaching dietary modifications to a client with hypertension. Which product is the best selection to include as part of the client's lunch?

A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

The nurse is assessing a 3-month-old client who had a pyloromyotomy yesterday. This child should be medicated for pain based on which finding(s)? Select all that apply.

A parent brings their 2-month-old infant to the clinic to receive the recommended primary vaccines. Which instruction should the nurse provide the parent about care of the infant after the injections?

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPS. Which intervention should the home health nurse implement to ensure adequate care for all clients?

A client is admitted to the mental health unit for feelings of depression secondary to a positive HIV report. To provide a safe milieu for this client, which action should the nurse take?

Exhibits Click to specify which client statement or behaviors is most likely associated with each of the listed defense mechanisms. Some statements or behaviors may be consistent with more than one mechanism. Each column must have at least one response selected.

Exhibits

The nurse is reviewing the client's chart.

For each finding, click to indicate whether 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.