Exit Exam (BSN 366)

The Correct Answer:

Check for a distended bladder.

Explanation:

A firm uterus that is positioned three fingerbreadths above the umbilicus on the first postpartum day is abnormal and suggests bladder distention. Normally, the uterus should be at or below the umbilicus as it involutes (shrinks) following delivery. A distended bladder can push the uterus upward and to the side, preventing proper contraction and increasing the risk of postpartum hemorrhage. The nurse’s first priority should be assessing the bladder and encouraging the patient to void if it is distended.

Why the Other Options Are Incorrect:

Increase IV infusion:

While increasing IV fluids might be necessary in cases of postpartum hemorrhage or hypovolemia, there is no indication that the patient is actively hemorrhaging. The presence of a moderate amount of lochia rubra and a firm uterus suggests that the bleeding is not excessive at this time. The priority is to assess the underlying cause of the elevated uterine position.

Massage the uterus to decrease atony:

Uterine atony (lack of muscle tone leading to excessive bleeding) would be suspected if the uterus were boggy (soft and non-firm). In this case, the uterus is firm, which means it is contracting appropriately. Massaging a firm uterus is unnecessary and could cause excessive stimulation, potentially leading to increased bleeding.

Review the hemoglobin to determine hemorrhage:

While monitoring hemoglobin levels is important for assessing blood loss, it is not the first priority in this situation. The key issue here is the abnormally high uterine position, which suggests bladder distention. Addressing this will help prevent further complications, including increased bleeding.

Correct Answer: Stool is eventually expelled through the rectum

An ileoanal reservoir, or J pouch, is a surgical procedure typically performed after removal of the colon and rectum, often due to ulcerative colitis. It involves creating a pouch from the ileum (end of the small intestine) and connecting it to the anal canal, enabling stool to pass through the rectum. This approach maintains continence and eliminates the need for a permanent external ostomy appliance. Over time, as healing progresses, the client can regain near-normal bowel function. This is the key educational point for clients undergoing this surgery, as it significantly affects their postoperative expectations and quality of life.

Why the other choices are incorrect:

The transverse loop ostomy is permanent

This is inaccurate. A transverse loop ostomy may be created temporarily during the healing period of a J pouch to divert stool and protect the new surgical connection. It is typically reversed after several weeks once the reservoir has healed. Suggesting permanence can create unnecessary anxiety and misinform the client about the temporary nature of this step in their recovery.

Easily removable appliances allow independence in self-care

While this is true for clients with a long-term ostomy, it does not apply to J pouch patients. The goal of a J pouch procedure is to avoid the need for external appliances altogether. Once healed, the client will not use a pouching system because stool will pass through the anus. This option describes care for a different surgical outcome, not the ileoanal reservoir.

Daily irrigation is started after the J pouch heals

Irrigation is generally associated with colostomies to regulate bowel movements, but it is not a part of routine care for a J pouch. Clients with a functioning J pouch do not require irrigation because stool is passed naturally through the rectum. This misconception may lead to inappropriate care practices and confusion about recovery expectations.

The correct answer is:

Obtain a blood pressure reading before the client gets out of bed.

Explanation:

After aortic valve replacement surgery, the client’s cardiovascular system is still adjusting, and the use of antidepressants and sedatives can increase the risk of hypotension, especially in older adults. By measuring the blood pressure before the client gets out of bed, the nurse can detect any orthostatic hypotension, which is a common post-operative concern. This helps prevent risks such as dizziness, fainting, and falls, which are significant concerns in older adults, particularly after major surgery. Early morning blood pressure monitoring ensures that the client’s blood pressure is stable before engaging in any activity that could worsen hypotension.

Why the Other Options Are Incorrect:

Measure and record the client’s urinary output every day

While monitoring urinary output is important for assessing kidney function and fluid status, it does not address the immediate concern of cardiovascular stability in this post-operative period. The primary concern in the early recovery phase after aortic valve replacement is ensuring that the client’s blood pressure remains stable, particularly when the client is getting out of bed.

Provide the client with teaching regarding a cardiac diet

Providing education on a cardiac diet is important for long-term heart health, but it is not the priority in the immediate post-operative phase. At this time, the focus should be on ensuring that the client’s current medical condition is stable, particularly regarding their blood pressure and response to medications. Dietary education can be provided once the client’s immediate needs are addressed.

Obtain client vital signs every four hours one week

Although regular vital sign monitoring is important, obtaining blood pressure specifically before the client stands is more targeted and necessary in this scenario. Blood pressure can fluctuate significantly in the post-operative phase, and monitoring it specifically before the client gets out of bed helps assess orthostatic hypotension, which can lead to falls and other complications. Routine vital signs monitoring every four hours is less focused and might not address the immediate risks associated with changes in position.

The correct answer is:

Observe the insertion site.

Explanation:

Observing the insertion site of a suprapubic catheter is essential to assess for signs of infection, leakage, or skin irritation. Suprapubic catheters are inserted through the abdominal wall into the bladder, and proper monitoring of the site ensures early detection of complications such as infection, inflammation, or dislodgement. The nurse should look for redness, swelling, discharge, or signs of pressure injury around the catheter site.

Why the Other Options Are Incorrect:

Assess the perineal area:

While perineal hygiene is important for overall urinary health, a suprapubic catheter bypasses the urethra. Assessing the perineal area is not as critical as monitoring the actual catheter insertion site for complications.

Palpate flank area:

Palpating the flank area is more relevant for assessing kidney issues, such as hydronephrosis or pyelonephritis, but it is not a routine assessment for a suprapubic catheter. The priority is to observe the catheter site for infection or complications.

Measure abdominal girth:

Measuring abdominal girth is not necessary for a client with a suprapubic catheter unless there is concern about bladder distension, fluid retention, or other abdominal complications. Regular assessment of urine output and catheter patency is more relevant.

Correct Answers:

Have a manual resuscitation bag at the bedside.

Ask the client about other medications she takes.

Take an initial respiratory rate.

Explanation:

These actions are crucial in ensuring the safe administration of morphine, especially in a postoperative setting where respiratory depression, sedation, and drug interactions are concerns.

Having a manual resuscitation bag at the bedside is important because morphine, being a potent opioid, can cause respiratory depression. In case the client experiences significant respiratory depression, having the necessary equipment for resuscitation can prevent complications and provide immediate ventilatory support.

Asking the client about other medications she is taking helps assess potential drug interactions. Certain medications, such as benzodiazepines, muscle relaxants, and other opioids, can interact with morphine to increase the risk of respiratory depression and sedation. Identifying these medications helps mitigate these risks.

Taking an initial respiratory rate before administering morphine helps establish a baseline for comparison. If the respiratory rate is low (below 12 breaths per minute), the nurse should withhold the medication and notify the healthcare provider to avoid worsening respiratory depression.

Why the Other Options Are Incorrect:

Performing a 12-lead electrocardiogram (ECG) is not necessary unless the client has a history of cardiac issues or shows signs of arrhythmias or hypotension. ECG monitoring is not routinely required before morphine administration unless specific cardiac concerns are present.

Suctioning the client to clear the airway is not necessary unless the client shows signs of airway obstruction, excessive secretions, or difficulty clearing the airway. Without these indications, suctioning is an unnecessary intervention.

Restraining the client with soft restraints is inappropriate for managing opioid side effects such as confusion or sedation. If the client is agitated or confused, assessing for hypoxia or adjusting the medication dose should be prioritized. Restraints should only be used in extreme cases where the client's safety is at risk, and all other options have been exhausted.

Correct Answer: Respirations of 10

Rationale:

Magnesium sulfate is commonly used in the management of severe preeclampsia, but it carries the risk of toxicity, particularly at higher doses. One of the most dangerous signs of magnesium sulfate toxicity is respiratory depression, characterized by a respiratory rate dropping below 12 breaths per minute. In this case, the client’s respiratory rate of 10 breaths per minute is a critical finding, signaling significant magnesium toxicity and requiring immediate discontinuation of the magnesium infusion. Respiratory depression can escalate to respiratory arrest if not promptly addressed, making this the priority intervention.

Explanation of Excluded Options:

Deep tendon reflexes 1+: A score of 1+ reflects a low-normal reflex response, which may be a sign of magnesium sulfate effect, but it’s not immediately life-threatening. Reflexes can decrease with rising magnesium levels, but they are less critical than respiratory depression in this case.

Blood pressure of 140/90: While elevated blood pressure is a concern in preeclampsia, it is not directly indicative of magnesium toxicity. Magnesium sulfate is primarily used to prevent seizures, and blood pressure may still be elevated even with appropriate magnesium levels.

Urinary output of 130 ml in 4 hours: This output equates to approximately 32.5 ml/hour, which is above the threshold for oliguria (typically defined as less than 30 ml/hour). Although reduced urine output can be a sign of magnesium toxicity, it is not the most urgent concern when compared to respiratory depression.

Correct Answer: Peanut butter crackers.

Explanation:

When managing hypoglycemia, the immediate goal is to quickly raise the blood glucose level and then provide a food that helps maintain it. The child in this scenario has a blood glucose level of 57 mg/dl, which is low and requires intervention. This option provides a combination of fast-acting carbohydrates (from the crackers) and protein/fats (from the peanut butter). The carbohydrates will raise the blood sugar quickly, and the protein/fat will help stabilize blood glucose levels over time. This combination makes it an ideal choice for both immediate correction and long-term stabilization after an episode of hypoglycemia.

Why the other options are incorrect:

A chocolate bar: While a chocolate bar contains sugar, it also has a high fat content, which can slow the absorption of glucose. In a hypoglycemic emergency, a quick-acting source of glucose, such as juice or a soft drink, would be more appropriate. A chocolate bar may not provide a fast enough glucose boost.

 A soft drink: A soft drink containing sugar is an excellent option for quickly raising blood glucose levels due to its high sugar content. However, while effective in the short term, it doesn't provide sustained glucose control. Peanut butter crackers (C) offer the best balance for both quick correction and longer-term stabilization of blood sugar.

A piece of bubble gum: Bubble gum contains minimal sugar and doesn’t provide enough of a glucose boost to effectively treat hypoglycemia. It’s not an adequate choice for managing low blood sugar levels.

Correct Answer:

Allow the bladder to empty completely or up to 1000 mL of urine.

Explanation:

When a straight catheter is inserted and an immediate output of 500 mL of clear yellow urine is observed, the next appropriate action is to allow the bladder to empty completely, or up to 1000 mL, as this ensures full bladder evacuation and helps prevent further complications such as urinary retention or bladder injury. Full bladder drainage is essential in relieving distention and preventing discomfort.

Why the Other Options Are Incorrect:

Removing the catheter and palpating the client's bladder for residual distention is not necessary immediately after catheterization. The goal is to allow the bladder to empty completely, not to assess for distention at this stage. Prematurely removing the catheter could lead to incomplete drainage, which might worsen retention.

Clamping the catheter for 30 minutes would only cause urine to accumulate, possibly resulting in bladder distention and discomfort. The aim is to allow complete and continuous drainage of the bladder to prevent retention, not to delay drainage by clamping.

There is no indication at this point that the client requires an indwelling catheter. The immediate need is to allow for complete drainage. A straight catheter is a temporary solution, and an indwelling catheter should only be considered if there are ongoing issues with retention or obstruction.

The correct answer is:

Dispose of soiled dressings in plastic bags that are securely closed.

Rationale:

When a client is on contact precautions due to an infected draining wound, it is crucial to minimize the risk of spreading the infection to others. Proper disposal of soiled materials, such as wound dressings, helps prevent contamination. Soiled dressings should be placed in plastic bags that are securely closed to prevent leakage and exposure, especially in the household environment, where there may be close contact with others.

Why the Other Choices Are Incorrect:

Use disposable plates and utensils:

While disposable plates and utensils may be useful in certain situations, such as with gastrointestinal infections, they are not typically required for contact precautions unless there is a specific risk of contamination with bodily fluids. Regular cleaning and disinfecting of reusable items would usually suffice for most contact precautions.

Stay in a room with the door closed:

Keeping the door closed is not a specific requirement for contact precautions unless the infection is highly contagious or there is particular advice from a healthcare provider. The focus for contact precautions at home is on proper hygiene, including handwashing, wearing gloves when handling the infected area, and proper disposal of contaminated materials.

Others who are in the same room with the client should wear a mask:

Wearing a mask is typically not necessary for contact precautions unless the infection is airborne or there is a respiratory risk. Contact precautions primarily focus on preventing the spread of infectious agents through direct contact with the client’s bodily fluids, so masks are not required unless specifically advised for respiratory concerns.