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","D","E"]

Explanation

Choice A rationale

Sending wound drainage for culture and sensitivity is a key step in diagnosing and treating VRE. This can help determine the most effective antibiotic treatment20.

Choice B rationale

There is no specific “low bacteria diet” recommended for VRE infections20.

Choice C rationale

Standard precautions, including wearing a mask, are important for preventing the spread of VRE1617181920.

Choice D rationale

Contact precautions, such as wearing gloves and gowns, are recommended for staff and visitors to prevent the spread of VRE1617181920.

Choice E rationale

Monitoring the client’s white blood cell count can help assess the body’s response to the infection and the effectiveness of treatment20.

A. She has mild subcostal retraction B. sitting in an upright position C. Wheezes are noted throughout the lung fields D. The client is pale E. Her heart rate is 122 beats/minute F. Oxygen saturation is 91% on room air G. strong peripheral pulses that are equal bilaterally H. client is admitted to the medical floor I. blood pressure 134/85 mm Hg

Correct Answer is ["A","B","C","D","E","F"]

Explanation

The assessment findings that require immediate follow up by the nurse are: The client has mild subcostal retractions. This could indicate that she is using accessory muscles to breathe, which is a sign of respiratory distress. The client is sitting in an upright position. This is a common position for people who are having difficulty breathing because it allows for maximum expansion of the lungs. Wheezes are noted throughout the lung fields. Wheezing can be a sign of an obstructive process such as asthma. The client is pale. Paleness can be a sign of decreased oxygenation. Her heart rate is 122 beats/minute, which is above the normal range and can indicate that her body is working harder to get oxygen. Her oxygen saturation is 91% on room air. Normal oxygen saturation is generally 95% or higher, so this could indicate that she is not getting enough oxygen.

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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

A client with a possible vancomycin-resistant enterococci (VRE) infection is admitted with purulent drainage from an abdominal surgical incision.What nursing interventions should be included in the plan of care? Select all that apply.

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

Explanation

Correct Answer is ["A","B","C","D","E","F"]

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?