The nurse has reviewed the patient’s chart.
The nurse recognizes that this patient is hemorrhaging due to which condition?

Uterine atony

Wound dehiscence

Infection

Hemorrhage

Answer and Explanation

The Correct Answer is A

Choice A rationale

Uterine atony refers to a condition where the uterus fails to contract sufficiently during and after childbirth. This lack of contraction can lead to excessive bleeding, also known as postpartum hemorrhage. This is because the contractions of the uterus after delivery help to compress the blood vessels and prevent bleeding. Therefore, uterine atony can cause a patient to hemorrhage.

Choice B rationale

Wound dehiscence refers to a surgical complication where an incision reopens either internally or externally. It can cause pain, infection, and organ protrusion. However, it is not directly associated with hemorrhaging.

Choice C rationale

Infection refers to the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. While severe infections can lead to sepsis and disseminated intravascular coagulation, which can cause bleeding, they do not directly cause hemorrhaging.

Choice D rationale

Hemorrhage is a symptom, not a condition. It refers to excessive bleeding which can occur due to various conditions, including uterine atony.

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Correct Answer is ["A","C","E"]

Explanation

A. Set up supplemental oxygen delivery- This could be necessary as the client is being weaned off the ventilator and may require additional oxygen support.
C. Gather supplies for extubation- As the client is being weaned off the ventilator and the pressure support has been decreased to 0 cm H2O, extubation may be imminent.
E. Offer the client ice chips- Once extubated, the client may have a dry mouth and throat from the intubation tube. Ice chips can help soothe the throat and keep the mouth moist.

B. Increase the fraction of inspired oxygen- This action is not indicated based on the information provided. The client’s oxygen saturation is within normal range and there’s no indication that the client is experiencing difficulty breathing or hypoxia.
D. Place a nasogastric tube- There’s no indication in the scenario that the client has a need for a nasogastric tube. This procedure is typically done for clients who have difficulty swallowing or need help with feeding, neither of which is mentioned in the scenario.
F. Suggest a different ventilator mode to the provider- The client is already being successfully weaned off the ventilator, as indicated by the decreasing pressure support. There’s no indication in the scenario that a different ventilator mode is needed.
G. Set the ventilator to give mandatory breaths- This action would be counterproductive to the weaning process. The client is already on a ventilator mode with no mandatory breaths and is being successfully weaned off the ventilator.

A. Prompt the nurse to apply povidone to the site. B. Direct the nurse to attach the luer-lock tip to the irrigation port. C. Send an unlicensed assistive personnel to gather equipment. D. Instruct the nurse to use water with 5% dextrose (D5W).

Correct Answer is B

Explanation

Choice A rationale

Prompting the nurse to apply povidone to the site is not the correct action in this scenario. Povidone-iodine is an antiseptic used for skin disinfection before and after surgery. It is not typically used in the process of irrigating an intravenous catheter.

Choice B rationale

Directing the nurse to attach the luer-lock tip to the irrigation port is the correct action. A luer-lock syringe is commonly used in medical procedures, including the irrigation of an intravenous catheter. The luer-lock tip provides a secure connection to prevent leaks and ensure that the irrigation solution is delivered directly to the catheter.

Choice C rationale

Sending an unlicensed assistive personnel to gather equipment is not the most appropriate action in this scenario. The new nurse has already gathered the necessary equipment for the procedure.

Choice D rationale

Instructing the nurse to use water with 5% dextrose (D5W) is not the correct action. D5W is a type of intravenous fluid used to correct dehydration and provide calories to the patient. It is not typically used for irrigating an intravenous catheter.

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The nurse has reviewed the patient’s chart.The nurse recognizes that this patient is hemorrhaging due to which condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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. Potential Actions

Correct Answer is ["A","C","E"]

Explanation

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

Correct Answer is B

Explanation

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The nurse has reviewed the patient’s chart.
The nurse recognizes that this patient is hemorrhaging due to which condition?