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 B
Explanation
A. “I will position my arms away from my body when pushing an object.”: Keeping the arms away from the body increases strain on the shoulders and back, raising the risk of musculoskeletal injury. Proper technique involves keeping objects close to the body to reduce stress on joints and muscles.
B. "I will position my body to face an object, so I avoid twisting”: Facing the object directly while lifting or moving it helps maintain proper body alignment and prevents spinal rotation, which reduces the risk of back injuries. This demonstrates correct understanding of safe body mechanics.
C. "I will position my legs close together before lifting”: Keeping legs close together decreases stability and increases the likelihood of losing balance or straining the back. A wider stance is recommended to provide a stable base of support when lifting.
D. “I will position objects away from my body before lifting them.”: Holding objects away from the body increases leverage on the spine and muscles, elevating the risk of strain or injury. Objects should be kept close to the body during lifting to minimize stress on the back.
Correct Answer is D
Explanation
A. Fundus is located 2 cm (0.4 in) below the level of the umbilicus: A fundus slightly below the umbilicus 24 hours postpartum is expected as the uterus involutes. This is a normal finding and does not require immediate reporting unless accompanied by excessive bleeding or other concerning signs.
B. Scant lochia rubra on the perineal pad: Scant lochia rubra is typical within the first 24 hours postpartum, indicating normal uterine shedding. It is expected and does not indicate a complication in the absence of heavy bleeding or foul odor.
C. Non-pitting bilateral peripheral edema: Mild non-pitting edema in the lower extremities can occur postpartum due to fluid shifts and is usually self-limiting. It is not typically emergent unless accompanied by severe swelling, pain, or signs of deep vein thrombosis.
D. Oral temperature of 38.8° C (101° F): An elevated temperature above 38° C 24 hours postpartum may indicate infection, such as endometritis or urinary tract infection. This finding requires immediate reporting to the RN for further assessment and intervention.
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