A nurse is assisting with the care of a client who has had a prostatectomy.
Select the 2 actions the nurse should prepare to take for the client.
Encourage prolonged dangling before ambulation.
Encourage oral fluid intake.
Assist the client with a sitz bath.
Irrigate indwelling catheter with 500 mL of fluid.
Administer an enema.
Correct Answer : B,C
A. Encourage prolonged dangling before ambulation: While dangling at the bedside can help prevent orthostatic hypotension, the client is already ambulating independently without reported dizziness or hypotension. Prolonged dangling is unnecessary and does not address the current issues of urinary discomfort and bowel cramping.
B. Encourage oral fluid intake: Adequate hydration helps maintain urine flow, prevent catheter obstruction, and support bowel function. Encouraging fluids also helps dilute urine, reducing bladder irritation and the risk of infection, which is especially important post-prostatectomy.
C. Assist the client with a sitz bath: A sitz bath can relieve perineal discomfort, reduce pain, and promote relaxation of the pelvic muscles. Given the client’s bladder fullness and postoperative cramping, this noninvasive intervention helps improve comfort and facilitate urination.
D. Irrigate indwelling catheter with 500 mL of fluid: Routine irrigation with such a large volume is not recommended and may cause trauma or introduce infection. Catheter irrigation should only be performed according to provider prescription and typically with small, prescribed amounts.
E. Administer an enema: The client reports only a single hard, painful bowel movement, and routine enema administration is not indicated. Enemas should be reserved for severe constipation or impaction, and inappropriate use can cause irritation or fluid shifts.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Droplet precautions: Droplet precautions are used for infections transmitted by large respiratory droplets, such as influenza or pertussis. Herpes simplex is not spread through respiratory droplets, so droplet precautions are not necessary.
B. Protective environment: A protective environment is designed to protect immunocompromised clients from acquiring infections. It is not used for clients who are infectious, such as those with herpes simplex.
C. Contact precautions: Herpes simplex virus is transmitted via direct contact with lesions or infected bodily fluids. Contact precautions, including wearing gloves and gowns and proper hand hygiene, prevent transmission to healthcare workers and other clients.
D. Airborne precautions: Airborne precautions are reserved for infections transmitted via small droplet nuclei, such as tuberculosis or measles. Herpes simplex does not spread through the airborne route, so these precautions are unnecessary.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
Rationale for correct choices:
• Placental abruption: The client exhibits sudden-onset hypertension, epigastric pain, headache, and facial edema at 30 weeks gestation, which are risk factors for placental abruption. Abruption involves premature separation of the placenta from the uterine wall, leading to maternal and fetal compromise. Early recognition is critical due to potential hemorrhage, fetal distress, and preterm delivery.
• Hypertension: The client’s blood pressure readings (148/94 mm Hg and 156/96 mm Hg) are significantly elevated for gestation, indicating preeclampsia or gestational hypertension. Hypertension increases the risk for placental abruption by causing vascular injury and reduced placental perfusion.
Rationale for incorrect choices:
• Postpartum hemorrhage: Postpartum hemorrhage occurs after delivery and is not a risk during the antepartum period at 30 weeks. While abruption can lead to bleeding, postpartum hemorrhage specifically refers to hemorrhage after birth and is not directly indicated by current findings.
• Placenta previa: Placenta previa involves implantation of the placenta over or near the cervical os, often presenting with painless vaginal bleeding. The client reports epigastric pain, headache, and hypertension, which are not characteristic of placenta previa.
• Hyperreflexia: While hyperreflexia is noted (DTRs 3+ bilaterally) and may indicate preeclampsia, it is a clinical finding rather than a direct cause of placental abruption. It is an important assessment parameter but does not independently increase the risk of abruption.
• Vomiting: Vomiting is a symptom the client reports but is not a primary risk factor for placental abruption. It may indicate associated preeclampsia or general discomfort but does not contribute directly to vascular placental separation.
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