The nurse is caring for a postoperative client who has a saline lock and minimal urine in the drainage bag, who appears anxious and restless. The nurse notices that the client's hands are cool and moist, with prolonged capillary refill. Which action should the nurse take?

Place a warm blanket on the client.

Administer IV fluids per protocol.

Review the medication administration record.

Check the urinary catheter r an occlusion.

Answer and Explanation

The Correct Answer is B

A. Place a warm blanket on the client: Providing warmth may improve comfort temporarily but does not address the underlying cause of the client’s cool, moist hands, prolonged capillary refill, or low urine output, which suggest possible hypovolemia or shock.

B. Administer IV fluids per protocol: The client’s signs restlessness, cool clammy skin, prolonged capillary refill, and low urine output indicate hypoperfusion likely due to fluid deficit. Administering IV fluids promptly helps restore circulating volume and tissue perfusion.

C. Review the medication administration record: While medication review is important for overall safety, it does not address the immediate risk of hypovolemic shock or low urine output in this client.

D. Check the urinary catheter for an occlusion: Although checking for blockage is reasonable if a catheter is present, the client’s overall clinical presentation points to systemic hypovolemia rather than a localized urinary obstruction.

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Correct Answer is D

Explanation

A. Increase in pulse and fetal rate reactivity: While changes in maternal pulse and fetal heart rate can indicate stress or early compromise, these findings alone do not specifically indicate acute maternal hemorrhage or uterine injury that requires immediate intervention.

B. Pain in lower quadrant and oliguria: These signs suggest possible urinary retention or renal compromise but are not the most urgent indicators of acute obstetric bleeding during labor.

C. Mild discomfort and elevated blood pressure: Mild discomfort and hypertension may reflect preeclampsia but do not specifically signal active hemorrhage requiring immediate reporting.

D. Sharp fundal pain and uterine tenderness: These findings are indicative of uterine rupture or abruption, both of which are obstetric emergencies. Profuse vaginal bleeding with uterine tenderness requires immediate notification of the healthcare provider to prevent maternal and fetal morbidity or

A. Use a picture of clock to indicate the dose times. B. Mark the dose on the syringe using color coded tape. C. Instruct them to add the medication to formula or juice. D. Place a color code on the medication containers. E. Schedule medication times with feeding times.

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

Explanation

A. Use a picture of a clock to indicate the dose times: Visual aids help parents with limited literacy or cognitive challenges understand when to give medications, improving adherence and safety.

B. Mark the dose on the syringe using color-coded tape: Color-coded markings provide a clear, simple guide for accurate dosing, reducing the risk of errors.

C. Instruct them to add the medication to formula or juice: Mixing medications with food or drink can alter absorption, interfere with effectiveness, or result in incomplete ingestion. This practice is generally discouraged unless specifically approved by the healthcare provider.

D. Place a color code on the medication containers: Color-coded containers help parents quickly identify the correct medication and dose, supporting safe administration.

E. Schedule medication times with feeding times: Aligning medication administration with regular daily routines such as feeding helps parents remember doses and promotes adherence to the prescribed schedule.

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The nurse is caring for a postoperative client who has a saline lock and minimal urine in the drainage bag, who appears anxious and restless. The nurse notices that the client's hands are cool and moist, with prolonged capillary refill. Which action should the nurse take?

Nursing Test Bank

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A client in labor begins bleeding profusely from the vagina. Which findings should the nurse report to the healthcare provider?

Correct Answer is D

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The parents of an infant with chronic health conditions have cognitive challenges and diverse educational backgrounds. Which intervention(s) should the nurse implement to support them in safely administering medications to their child? Select all that apply.

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