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.

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Correct Answer is B

Explanation

Rationale

A. Repositioning the stethoscope or reinflating the cuff may be necessary if the sounds are unclear or if there is difficulty in hearing the Korotkoff sounds, but these actions come after noting any auscultatory gap.

B. It's characterized by a period of silence between the appearance and disappearance of sounds. Noting its presence is important for accurately recording the blood pressure readings, as failure to recognize an auscultatory gap could lead to underestimating the systolic pressure.

C. After repositioning the stethoscope or noting the presence of an auscultatory gap, the nurse should proceed with the blood pressure assessment.

D. If the cuff was not inflated adequately during the initial inflation, the nurse may not have occluded the artery completely, leading to inaccurate readings. However, in this scenario where Korotkoff sounds

are heard, it indicates that the cuff pressure was sufficient to occlude and then release the artery's blood flow.

A. Increase the fraction of inspired oxygen B. Suggest a different ventilator mode to the provider C. Offer the client ice chips D. Set the ventilator to give mandatory breaths E. Set up supplemental oxygen delivery F. Gather supplies for extubation G. Place a nasogastric tube

Correct Answer is ["B","E","F"]

Explanation

A. Since the client is already on a fraction of inspired oxygen (FIO2) of 35% and has successfully weaned off the ventilator, increasing the FIO2 may not be necessary unless the client's oxygenation status deteriorates post-extubation.
B. As the client has successfully weaned off pressure support and is now at 0 cm H2O, the healthcare provider may consider transitioning to a different ventilator mode such as T-piece or CPAP (Continuous Positive Airway Pressure) to further assess the client's ability to breathe spontaneously without ventilator support.
C. Ice chips are typically offered to conscious patients to alleviate thirst or dry mouth. The client was previously intubated and may not be fully conscious or able to swallow safely immediately post- extubation.
D. Since the client has been weaned off pressure support successfully, there is no indication to set the ventilator to provide mandatory breaths. The focus is on assessing the client's ability to breathe spontaneously.
E. Even though the client has been weaned off the ventilator, it's important to ensure adequate oxygenation. Setting up supplemental oxygen delivery, such as via nasal cannula or face mask, can support the client's oxygen needs during the transition phase post-extubation.
F. Since the client has been successfully weaned to 0 cm H2O pressure support and the healthcare provider is evaluating the client, gathering supplies for potential extubation is appropriate. This includes ensuring all necessary equipment and supplies for a safe extubation procedure are readily available at the bedside.
G. Unless specifically indicated for other medical reasons not mentioned, there is no immediate need to place a nasogastric tube based on the information provided about the client's current condition post- weaning.

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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

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

Correct Answer is B

Explanation

Exhibits The nurse notifies the healthcare provider of the client's status. The healthcare provider comes to the bedside to evaluate the client. Which should the nurse do? Select all that apply.

Correct Answer is ["B","E","F"]

Explanation

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?

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.

The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?

A client arrives at a hurricane disaster medical area seeking treatment for diarrhea. Which source of contamination should the nurse consider when interviewing the client about exposure?

Which instruction should the nurse provide to a client who is preparing to have a cystoscopy?

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

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.