A nurse on an obstetrics-gynecology unit is planning care for four clients after receiving change of shift report. Which of the following clients should the nurse assess first?
A client who is 4 days postpartum and has mastitis
A client who had a bilateral tubal ligation 12 hr previously
A client admitted 1 hr ago for an ectopic pregnancy
A client who is a 1 day postpartum after a late term miscarriage
The Correct Answer is C
Rationale:
A. A client who is 4 days postpartum and has mastitis should be assessed, but this condition is less acute compared to the others.
B. A client who had a bilateral tubal ligation 12 hr previously requires post-operative monitoring, but this is less urgent than the client with an ectopic pregnancy.
C. A client admitted 1 hr ago for an ectopic pregnancy is the priority as this condition can be life-threatening and requires immediate assessment.
D. A client who is 1 day postpartum after a late-term miscarriage requires care, but the immediacy is less than that of the ectopic pregnancy client.
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Correct Answer is ["A","D","E"]
Explanation
Rationale:
A. While pulling the fire alarm is correct, removing the client from the room without following the full RACE sequence (Remove, Alarm, Confine, Extinguish/Evacuate) is incorrect. The immediate safety measures should include ensuring that the alarm is activated before evacuation and confining the fire if possible.
B. Verifying the order of protective equipment removal with the nurse shows a good practice and adherence to proper infection control procedures.
C. Washing hands prior to leaving the room after disinfecting equipment indicates proper infection control practice.
D. Handwashing is a crucial aspect of infection control. Failure to perform hand hygiene during or after patient care increases the risk of infection transmission. Immediate follow-up is needed to ensure that proper hand hygiene practices are adhered to.
E. Knowing the locations of alarms is vital for effective fire safety. Inability to identify these locations indicates a significant gap in preparedness for emergencies. Immediate follow-up is necessary to ensure that staff are familiar with fire safety procedures and equipment locations.
F. Successfully completing the skills in simulation, including emptying the client's trash can, shows adherence to task requirements but is not a critical issue requiring immediate follow-up compared to the other findings.
Correct Answer is C
Explanation
Rationale:
A. "I had strep throat about one year ago" is not directly related to contraindications for glyburide.
B. "I got my flu shot at the pharmacy two weeks ago" does not affect the use of glyburide.
C. "I plan to continue nursing my baby until he is at least a year old" indicates a contraindication because glyburide is not recommended for use during breastfeeding due to potential effects on the infant.
D. "I am allergic to shellfish" is not relevant to the contraindications for glyburide.