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 C

Explanation

A. Difficulty swallowing: Difficulty swallowing is more commonly associated with cranial nerve involvement, neuromuscular disorders, or medication side effects rather than pain perception. It does not reliably reflect inadequate pain control following a spinal epidural. Difficulty swallowing would prompt evaluation of airway or neurologic status rather than pain relief.

B. Urinary retention: Urinary retention is a known effect of spinal or epidural anesthesia due to temporary blockade of sacral nerves. It reflects autonomic nervous system involvement rather than the client’s pain level. Retention can occur even when pain is adequately managed.

C. Restlessness: Restlessness is a common behavioral indicator of unrelieved pain, especially when pain persists despite treatment. Clients may appear unable to relax, frequently change positions, or seem agitated when discomfort is not controlled. This finding suggests the need for reassessment of pain management effectiveness.

D. Constipation: Constipation is associated with opioid use, reduced mobility, or decreased gastrointestinal motility rather than uncontrolled pain. It develops over time and is not an acute indicator of ineffective pain relief. It would prompt bowel management rather than pain reassessment.

A. Hyperglycemia B. Hand tremors C. Nausea D. Swelling of the lips

Correct Answer is D

Explanation

A. Hyperglycemia: Epinephrine is not used to treat elevated blood glucose levels. Its primary action is to counteract severe allergic reactions, not metabolic disturbances such as hyperglycemia.

B. Hand tremors: Hand tremors can be a side effect of epinephrine rather than an indication for its use. Tremors are related to its sympathomimetic effects on the nervous system and are not treated by the medication.

C. Nausea:Although nausea can occur during allergic reactions, it is not the primary manifestation indicating the need for an epinephrine auto-injector.

D. Swelling of the lips:An epinephrine auto-injector is used to treat anaphylaxis, a severe allergic reaction. Swelling of the lips is a sign of angioedema and airway involvement, which can rapidly progress to airway obstruction. Epinephrine works by causing vasoconstriction, bronchodilation, and reduced mucosal edema, making it the first-line treatment for severe allergic reactions.

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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.