A nurse is assisting in the care of a client who is 1 hr postpartum.
Exhibit 1
Nurses' Notes
1200:
Large amount of lochia rubra noted on perineal pad.
... [Show More] Fundus boggy at two
fingerbreadths above the umbilicus. Oxytocin 20 units being administered via
continuous IV infusion
1215:
Large amount of lochia rubra with several large clots noted. Client reports feeling
anxious. Skin cool and clammy. Provider notified.
Exhibit 2
Vital Signs
1200:
Temperature 37.5° C (99.5° F) Heart rate 92/minRespiratory - Select the 6 actions
the nurse should take.
Weigh the perineal pads.
Insert an indwelling urinary catheter.
Administer methylergonovine.
Provide emotional support.
Administer oxygen at 12 L/min via nonrebreather face mask.
Firmly massage the uterine fundus.When taking action for the client, the nurse should firmly massage the uterine
fundus, administer methylergonovine, weigh the perineal pads, provide emotional
support, insert an indwelling urinary catheter, and administer oxygen at 12 L/min
via nonrebreather face mask. The nurse should identify that the client is
experiencing a postpartum haemorrhage, which requires immediate intervention to
prevent haemorrhagic shock.
A nurse is collecting data from a client who is scheduled for surgery.
Exhibit 1
Vital Signs
0630:
Temperature 36.9° C (98.5° F) Heart rate 74/minRespiratory rate 20/minBlood
pressure 122/76 mmHgOxygen saturation 96% on room air
0730:
Temperature 36.9° C (98.5° F)Heart rate 76/minRespiratory rate 20/minBlood
pressure 128/78 mmHgOxygen saturation 95% on room air
Exhibit 2
Nurses' Notes
0630:
Client reports restlessness and inability to sleep more than 3 to 4 hr per night for
the last week. Cli - Click to highlight the data collection findings that the nurse
should report to the provider prior to the procedure. To deselect a finding, click on
the finding again.
Haemoglobin level
Allergy
Family historyWhen collecting data from the client and analyzing cues, the nurse should
determine the client's hemoglobin level, latex allergy, and family history of
malignant hyperthermia should be reported to the provider. When the client's
hemoglobin level is below the expected range, the client might require blood
products during the intraoperative phase. The client's allergy to avocados and
bananas can indicate an allergy to latex products and should be reported to the
provider. The surgical team will need to remove all latex products from the
operating room. During the intraoperative phase, the nurses must be diligent in
monitoring the client's vital signs and laboratory values, especially in a client who
has a family history of malignant hyperthermia.
A nurse is caring for a client who is recovering from a stroke and is experiencing
difficulty using eating utensils. The nurse should identify the need for a referral to
which of the following interprofessional team members? - Occupational therapist
The nurse should identify the need for a referral to an occupational therapist to
teach the client how to use special eating utensils.
A nurse is reviewing the electronic health records of four clients. Which of the
following client conditions should the nurse recognize as reportable to a regulatory
agency? - A client who is newly diagnosed with tuberculosis
The nurse should identify that certain communicable diseases, such as tuberculosis,
require notification of the local and state health departments.
A nurse is caring for a client who is being discharged home following a
cerebrovascular accident. Which of the following documents should the nurse plan
to include with the discharge report? - List of potential complications to reportDischarge instructions are defined as any form of documentation provided to the
client, upon discharge to home, which facilitates safe and appropriate continuity of
care. The nurse should plan to include a list of potential complications that should
be reported to the provider in the client's discharge instructions.
A nurse is reinforcing teaching with the parent of a preschooler who has lactose
intolerance. Which of the following statements by the parent indicates an
understanding of the teaching? - "I should offer my child yogurt that has a
probiotic as a snack."
Children who have lactose intolerance should be offered dairy products that have a
probiotic, such as lactobacillus. The probiotic promotes tolerance of lactose in the
colon.
A nurse is reinforcing teaching for a client who has type 1 diabetes mellitus. Which
of the following client statements indicates an understanding of the teaching? - "I
should check my blood sugar if my appetite is decreased."
The nurse should instruct the client to monitor blood glucose levels closely.
Change in appetite can be an early sign of hyperglycemia and inadequate intake
may cause blood glucose to drop.
A nurse is collecting data from a client who has iron deficiency anemia. Which of
the following findings should the nurse expect? - Difficulty concentrating
In clients who have iron deficiency anemia, body cells do not receive the required
oxygen because there is less hemoglobin for binding. The nurse should recognize
that impaired oxygenation of brain tissue can lead to dizziness and difficulty
concentrating.A nurse is caring for a client who is immunocompromised. Which of the following
immunizations is contraindicated? - Measles, mumps, and rubella (MMR)
The MMR vaccine consists of a live virus and is contraindicated for a client who is
immunocompromised.
A nurse is caring for a client who has expressive aphasia following a stroke. Which
of the following methods should the nurse use when communicating with the
client? - Provide a picture board.
A client who has expressive aphasia has difficulty expressing needs or wants
through verbalization or writing. The use of a picture board provides an alternative
means of communication that might be less frustrating for the client.
A nurse is preparing to administer insulin to a client who has type 1 diabetes
mellitus. After drawing up the medication, the nurse accidentally brushes the
needle on the counter's surface. Which of the following actions should the nurse
take? - Prepare a new dose of insulin for injection.
Insulin is administered using an insulin syringe with a preattached needle.
Therefore, to ensure the sterility of the needle, the nurse should prepare a new dose
of insulin for injection using a new syringe and new dose of insulin. [Show Less]