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1. A nurse is assisting in the care of a weigh the perineal pads, provide emotional support,
client who is 1 hr postpartum. insert an indwelling urinary catheter, and administer
1200: oxygen at 12 L/min via nonrebreather face mask.
Large amount of lochia rubra noted
on perineal pad. Fundus boggy at
two fingerbreadths above the um-
bilicus.Oxytocin 20 units being ad-
ministered via continuous IV infu-
sion
1215:
Large amount of lochia rubra with
several large clots noted. Client re-
ports feeling anxious. Skin cool and
clammy. Provider notified.
Vital Signs
1200:
Temperature 37.5° C (99.5°
F)Heart rate 92/minRespiratory
rate 22/minBlood pressure 100/60
mm HgSaO2 97% on room
air1215:
Temperature 37.1° C (98.8°
F)Heart rate 112/minRespiratory
rate 26/minBlood pressure 90/52
mm HgSaO2 92% on room air
Select the 6 actions the nurse
should take.
2. WHAT SHOULD THE NURSE RE- During the intraoperative phase, the nurses must be
PORT PRIOR TO THE PROCEDURE: diligent in monitoring the client's vital signs and labora-
0630:
, PN Comprehensive Online Practice 2025 PT 1
Study online at https://quizlet.com/_h6njst
Temperature 36.9° C (98.5° tory values, especially in a client who has a family history
F)Heart rate 74/minRespiratory of malignant hyperthermia.
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
0630:
Client reports restlessness and in-
ability to sleep more than 3 to 4 hr
per night for the last week. Client
reports pain of 2 on a scale of 0
to 10, constant for 2 weeks and in-
creases after meals.
0730:
Creatinine 0.9 mg/dL (0.5 to 1.1
mg/dL)Hct 43% (42% to 52%)Hgb
12 g/dL (14 to 18 g/dL)
0630:
Client is 68 years old, diagnosed
with cholelithiasis 2 weeks ago af-
ter reports of right upper quad-
rant pain rated 8 on a scale of 0
to 10 after meals. Family history
of coronary artery disease and ma-
lignant hyperthermia.Reports aller-
gy to avocados and bananas.No
known allergies to medications.
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Study online at https://quizlet.com/_h6njst
0700:
Lung
3. NURSE CARING FOR A CLIENT WHO SPEECH THERAPIST
IS RECOVERING FROM A STROKE
AND EXPERIENCING DIFFICULTY
USING UTENSILS, NURSE SHOULD
IDENTIFY THE REFERRAL TO WHICH
INTERPROFESSIONAL TEAM
4. NURSE REVIEWING ELECTRONIC The nurse should identify that certain communicable
HEALTH RECORDS OF 4 CLIENTS , diseases, such as tuberculosis, require notification of
WHICH OF THE FOLLOWING CON- the local and state health departments.
DITIONS SHOULD THE NURSE REC-
OGNIZE AS REPORTABLE TO REGU-
LATORY AGENCY
5. WHAT SHOULD BE INCLUDED IN Discharge instructions are defined as any form of doc-
THE DOCUMENTATION FOR A PT umentation provided to the client, upon discharge to
BEING DISCHARGED FOLLOWING home, which facilitates safe and appropriate continu-
CEREBROVASCULAR ACCIDENT ity 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.
6. TEACHING FOR A PARENT WITH Children who have lactose intolerance should be of-
PRESCHOOLER WHO HAS LACTOSE fered dairy products that have a probiotic, such as lac-
INTOLERANCE , WHICH INDICATES tobacillus. The probiotic promotes tolerance of lactose
A UNDERSTANDING? in the colon.
7. REINFORCING TEACHING TO A The nurse should instruct the client to monitor blood
CLIENT THAT HAS TYPE 1 DM , glucose levels closely. Change in appetite can be an
WHICH OF THE FOLLOWING IN- early sign of hyperglycemia and inadequate intake may
cause blood glucose to drop.