A nurse is caring for a client who is requesting to go to the bathroom immediately after a vaginal birth. Which of the following actions should the nurse take?

Inform the client that she can go to the bathroom whenever needed.

Advise the client to remain in bed for the next few hours.

Assist the client to the bathroom and assess the lochia.

Evaluate the side effects of any analgesics used during labor.

Answer and Explanation

The Correct Answer is C

b) Return the patient to bed and maintain bed rest until the local ﬂow stabilizes.

Explanation: The patient experienced a sudden guard while being assisted to the bathroom, which led to their hospitalization. The most appropriate action for the practical nurse (PN) in this situation is to prioritize the patient's safety and well-being. Returning the patient to bed and maintaining bed rest allows for stability and minimizes the risk of further complications or injury. By providing a safe and controlled environment, the PN can monitor the patient's condition and collaborate with the healthcare team to determine the appropriate course of action moving forward. Options a), c), and d) are not relevant or appropriate in this context.

a) Maximize funding and avoid undue pressure on the cesarean incision: This option is unrelated to the situation described. It mentions maximizing funding, which is not relevant to the patient's condition, and does not address the sudden guard experienced during bathroom assistance.

b) Adjust ﬂuid consistency and continue to monitor the local ﬂow amount: This option is not applicable to the situation described. It suggests adjusting ﬂuid consistency and monitoring local ﬂow, which do not address the sudden guard experienced by the patient.

c) Withhold bladder emptying until the Foley catheter is removed and contract the fundus: This option is not appropriate for the situation described. It refers to withholding bladder emptying until the Foley catheter is removed, which may not be necessary or relevant in this case. Contracting the fundus is also unrelated to the sudden guard experienced during bathroom assistance.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","D","F","I"]

Explanation

Choice A rationale:
Starting an insulin drip at 0.1 u/kg/hr is a common treatment for diabetic ketoacidosis (DKA). The goal is to lower blood glucose levels while avoiding a rapid decrease that could lead to cerebral edema. Insulin infusions allow for precise control of the rate and can be adjusted as needed based on the patient’s response.
Choice B rationale:
Giving a long-acting insulin dose is not typically done during the acute treatment of DKA. The patient has already taken a dose of insulin glargine at home. Additional doses of long-acting insulin could potentially lead to hypoglycemia.
Choice C rationale:
Providing an oral medication that enhances insulin production would not be beneficial in this case. The patient has type 1 diabetes, which means her body does not produce insulin. Therefore, medications that stimulate insulin production would not be effective.
Choice D rationale:
Changing the intravenous fluid to 5% dextrose and 0.45% sodium chloride with 20 mEq potassium can help prevent hypoglycemia and hypokalemia, which are potential complications of DKA treatment. As blood glucose levels decrease with treatment, dextrose can help maintain appropriate glucose levels. Potassium is often depleted in DKA and needs to be replaced.
Choice E rationale:
Having the client drink as much as they can tolerate would not be appropriate at this time. The patient is currently experiencing nausea and vomiting, which could be exacerbated by oral fluid intake. Additionally, she is NPO (nothing by mouth), likely due to her unstable condition.
Choice F rationale:
Giving 1 L of 0.9% sodium chloride IV can help correct dehydration, which is common in DKA due to excessive urination caused by high blood glucose levels.
Choice G rationale:
Promoting the removal of electrolytes with a diuretic would not be beneficial in this case. The patient is likely already dehydrated and may have electrolyte imbalances due to DKA. Using a diuretic could exacerbate these issues.
Choice H rationale:
Giving a multivitamin is not typically part of the acute treatment for DKA. While overall nutritional status is important in managing diabetes, it would not address the immediate concerns of hyperglycemia and acidosis in DKA.
Choice I rationale:
Replacing potassium as needed is crucial in the treatment of DKA. Potassium levels can drop rapidly during treatment as insulin allows potassium to move back into cells. Low potassium (hypokalemia) can cause dangerous heart rhythms and muscle weakness.

A. Tachycardia B. Hyperglycemia C. Bronchospasm D. Hyperkalemia.

Correct Answer is C

Explanation

The correct answer is: C. Bronchospasm.

Metoprolol is a selective beta-1 blocker, primarily affecting the heart, but it can still have some impact on beta-2 receptors in the lungs. In clients with respiratory conditions like asthma or COPD, beta-blockers can trigger bronchospasm, leading to breathing difficulties.

Here's why the other options are less likely to be adverse effects of metoprolol:

A. Tachycardia: Metoprolol actually lowers heart rate, so tachycardia is not a typical adverse effect. Instead, bradycardia (slow heart rate) is more common.
B. Hyperglycemia: Beta-blockers can sometimes mask symptoms of hypoglycemia, but they don’t directly cause high blood sugar.
D. Hyperkalemia: Metoprolol doesn’t significantly affect potassium levels, so hyperkalemia is not a common concern.

Since metoprolol is frequently used in hypertension management, nurses must monitor clients for bradycardia, hypotension, and signs of bronchospasm, especially in individuals with respiratory disorders.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who is requesting to go to the bathroom immediately after a vaginal birth. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data. Exhibits The nurse has called the physician and is anticipating orders. Select the actions that would help with the listed treatment goals. Select all that apply.

Correct Answer is ["A","D","F","I"]

Explanation

A nurse is caring for a client who has hypertension and is prescribed metoprolol, a beta blocker. The nurse should monitor the client for which of the following adverse effects?

Correct Answer is C

Explanation

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to an unlicensed assistive personnel (UAP)?

Before administering an antibiotic that can cause nephrotoxicity, which laboratory value is most important for the practical nurse (PN) to review?

A nurse is providing interventions for a client with panic disorder.Which interventions should the nurse include in the plan of care? (Select all that apply).

The nurse is preparing a community outreach program on primary disease prevention.Which topic should the nurse plan to include in this event?

When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? (Select all that apply.).

A client who has been prescribed propranolol for the treatment of arrhythmias reports experiencing shortness of breath and difficulty breathing while lying down at night.Which of the following should the nurse instruct the client to do?

A client who weighs 176 pounds receives a prescription for norepinephrine 2 mcg/min intravenously (IV). The IV bag is labeled, "Norepinephrine 4 mg in dextrose 5% in water (D; W) 1,000 mL." How many mL/hour should the nurse program the infusion pump? (Enter numerical value only.).