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NURS 405 PassPoint 1

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WITH 100 Q&A Question 1 During the fourth stage of labor, a nurse notes that the client's fundus is boggy and located above the umbilicus. How should the nurse intervene? Correct response: • Massage the client's f ...

WITH 100 Q&A Question 1 During the fourth stage of labor, a nurse notes that the client's fundus is boggy and located above the umbilicus. How should the nurse intervene? Correct response: • Massage the client's fundus. Explanation: A boggy (soft and poorly contracted) fundus signals uterine atony. To correct this condition, the nurse should massage the fundus until it becomes firm and clots are expressed. Allowing a boggy fundus to persist would place the client at high risk for postpartum hemorrhage. Bearing down doesn't affect uterine involution. The nurse should notify the physician only if the client's fundus doesn't respond to massage. Question 2 Which nursing action is most beneficial to prevent fungal infections in hospitalized clients? Correct response: • Dry all skin folds thoroughly Explanation: Fungus spreads in warm, moist environments. The nurse must keep all skin folds on the warm body dry. Moisturized is needed for dry skin but does not prevent fungal infections. Bathing is appropriate but drying is key. Environmental air movement is not necessarily helpful. Question 3 A client with hepatitis B is visiting with her sister when the client's IV catheter dislodges and bleeds onto the surface of the bedside table. Which of the following, if observed, would cause the nurse to intervene? Correct response: • The nursing assistant uses tissue to blot up the blood. Explanation: The nursing assistant should have waited for housekeeping to clean up the blood. Cleaning with a bleach solution will kill the virus and prevent transmission. The use of tissues only adds to the risk of accidental transmission. The blood infected with the hepatitis B virus should be removed from the table or other surfaces with bleach. The client can hold pressure over the area. Asking the sister of the client to move from the area will protect her from accidental exposure. Question 4 The nurse is caring for a child with a life-threatening illness. The parents of the child want to introduce acupuncture and herbal medicines into the treatment regime. What is the most effective way for the nurse to react to this request? CONTINUED..........

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