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Exhibits

The nurse reviews the nurse's notes and flow chart to identify trends.

Click to specify the notations that require immediate follow up (more than one notation may be correct.)

Body System

Circulatory

Heart rate 96 beats/minute

Blood pressure 90/62 mm Hg

IV infusing at 125 ml/hr

Respirations 16 breaths/minute

Respiratory

Oxygen saturation of 89%

Several deep breaths

Integumentary

Episiotomy intact with no redness

Pad is saturated with blood

18 gauge IV to left forearm

Genital/Urinary

Boggy fundus 1 cm above umbilicus

Fundus rotated to the right

Voided 200 mL of clear yellow urine

Blood pressure 90/62 mm Hg

Oxygen saturation of 89%

Fundus rotated to the right

Voided 200 mL of clear yellow urine

Oxygen saturation of 89%

IV infusing at 125 ml/hr

Answer and Explanation

The Correct Answer is ["A","B","C"]

Blood pressure 90/62 mm Hg

A blood pressure of 90/62 mm Hg indicates hypotension, which could be indicative of hypovolemia (low blood volume) due to postpartum hemorrhage. Hypotension needs immediate evaluation and intervention to prevent further complications.

Oxygen saturation of 89%

An oxygen saturation of 89% on room air is below the normal range (typically 95-100%). This suggests the client is not adequately oxygenating, which could be due to various reasons such as respiratory compromise or inadequate ventilation. Immediate follow-up is necessary to determine the cause and initiate appropriate interventions.

Fundus rotated to the right

The displacement of the fundus could be due to the presence of a distended bladder pushing the uterus to one side which may increase uterine atony.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Rationale

A. Continuing with the tracheostomy care procedure while a code blue is ongoing for another client is not appropriate. A code blue takes precedence as it indicates a life-threatening emergency requiring immediate response.

B. Closing the room door is not a priority action during a code blue. The immediate focus should be on responding to the emergency and providing assistance as needed.

C. If additional help is needed to assist with the tracheostomy care procedure, calling for an assistant could be appropriate under normal circumstances. However, during a code blue, the primary responsibility is to respond to the emergency immediately.

D. A code blue indicates a cardiac or respiratory arrest, which requires immediate intervention. As a nurse, responding to the code blue involves providing assistance with cardiopulmonary resuscitation (CPR), fetching emergency equipment, and supporting the healthcare team in resuscitative efforts.

A. Diarrhea and flatulence. B. Muscle pain. C. Abdominal cramps. D. Altered taste.

Correct Answer is B

Explanation

Rationale

A. Diarrhea and flatulence are common gastrointestinal side effects of statin medications like lovastatin. While uncomfortable for the client, these symptoms are typically not serious and do not require immediate follow-up unless severe or persistent.

B. Muscle pain, also known as myalgia, is a potential side effect of statin therapy. In some cases, statins can cause muscle inflammation (myositis) or more severe muscle breakdown (rhabdomyolysis), which can lead to serious complications such as kidney damage. If a client reports new or worsening muscle pain, especially if accompanied by weakness, tenderness, or dark urine, it requires immediate follow-up to assess for these potential complications.

C. Abdominal cramps can occur as a gastrointestinal side effect of statins but are generally not considered a serious adverse reaction. They may improve with time or adjustments in diet or medication administration timing.

D. Altered taste, such as a metallic taste, is a less common side effect of statin therapy. While it can be bothersome, it is usually not serious and does not typically require immediate follow-up unless severe or persistent.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

Correct Answer is D

Explanation

Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

Correct Answer is B

Explanation

The nurse assesses the client after the dose of albuterol and documents the findings in the chart. Exhibits Which action(s) should the nurse plan for the rest of the shift? Select all that apply.

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?

While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

The parent of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The parent reports no evidence of watery stools. Which nursing intervention should the nurse implement?

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?