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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. This image shows Heberden's and Bouchard's nodes, which are bony enlargements of the finger joints typically associated with Osteoarthritis.

B. This image clearly shows the loss of the normal angle between the nail and the nail bed (Lovibond angle). The fingertips appear enlarged and "drumstick-like," and the nails have a distinct downward, convex curvature.

C. This image displays Ulnar Drift (the fingers slanting toward the pinky side) and joint swelling, which are classic manifestations of Rheumatoid Arthritis. It also shows age-related lentigines (liver spots) on the skin.

A. "We will wrap our baby in a blanket under the car seat straps when it is cold out." B. "We will make sure to activate the air bag when we place the car seat in the front passenger seat." C. "We will switch our baby's car seat to forward facing when they turn one." D. "We will check the temperature of the car seat surface before placing our baby in the seat when it is hot out."

Correct Answer is D

Explanation

A. "We will wrap our baby in a blanket under the car seat straps when it is cold out.": Placing a blanket under the straps can prevent proper restraint and reduce the effectiveness of the harness, increasing the risk of injury during a crash. Blankets should go over the secured straps instead.

B. "We will make sure to activate the air bag when we place the car seat in the front passenger seat.": Airbags can cause serious injury or death to infants in the event of a collision. Infants should always ride in the back seat, away from active airbags.

C. "We will switch our baby's car seat to forward facing when they turn one.": Current safety guidelines recommend keeping infants in a rear-facing car seat until at least 2 years of age or until they reach the maximum height and weight allowed by the car seat manufacturer.

D. "We will check the temperature of the car seat surface before placing our baby in the seat when it is hot out.": Checking the car seat’s surface temperature helps prevent burns from hot straps or seat material. This demonstrates understanding of infant safety measures during car seat use.

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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.

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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.