A nurse is caring for a client who is 1 hr postpartum and unable to urinate.
Which of the following actions should the nurse take?
Place the client's hands in warm water.
Perform a fundal massage.
Administer a benzodiazepine.
Place an ice pack on the client's perineum.
The Correct Answer is A
Choice A rationale:
Placing the client's hands in warm water is a method to stimulate urination and is appropriate for clients experiencing difficulty voiding.
Choice B rationale:
Performing a fundal massage is incorrect choice in this scenario.
Choice C rationale:
Administering a benzodiazepine is not appropriate for this situation. Benzodiazepines are a class of medications primarily used for anxiety, insomnia, and seizures. There is no indication for the use of benzodiazepines in this case, as the client's inability to urinate is likely related to a physiological issue postpartum, not anxiety or seizures.
Choice D rationale:
Placing an ice pack on the client's perineum is not the correct intervention for this situation. Ice packs on the perineum are typically used to reduce swelling and relieve pain after childbirth. However, the client's inability to urinate suggests a potential issue within the urinary system, and a fundal massage to promote uterine contractions would be more appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Encouraging fluid intake of 2,500 mL/day is the correct choice for a client with a fever due to an infection. Adequate hydration is essential in managing fever as it helps to prevent dehydration, maintain electrolyte balance, and support the body's immune response. Increasing fluid intake, preferably water, can also aid in lowering body temperature and promoting overall comfort.
Choice B rationale:
Maintaining the environmental temperature at 16°C to 18°C (60°F to 65°F) is not an appropriate intervention for a client with a fever. While it's essential to keep the client comfortable, adjusting the room temperature within a specific range is not the primary intervention. Focus should be on managing the fever through hydration, antipyretic medications, and addressing the underlying infection.
Choice C rationale:
Immersing the client in cold water is not a recommended intervention for managing fever. Cold water immersion can lead to shock, vasoconstriction, and potentially worsen the condition. It is essential to use methods like tepid sponging or cooling blankets if necessary, but these interventions should be performed under healthcare provider guidance and monitoring.
Choice D rationale:
Assisting the client to ambulate is a general nursing care activity and does not specifically address the fever due to infection. While ambulation is encouraged for many patients to prevent complications related to immobility, it is not the primary intervention for managing fever. The focus should be on hydration and other appropriate measures to reduce fever.
Correct Answer is B
Explanation
The correct answer is **b. A room containing personal belongings.**
Choice A rationale:
A room without a window would not be a therapeutic environment for a cognitively impaired client. Lack of natural light and connection to the outside world can be disorienting and distressing for these patients.
Choice B rationale:
A room containing personal belongings is the most therapeutic environment for a cognitively impaired client. Familiar objects and surroundings can help provide a sense of comfort, security, and orientation. This can reduce agitation and confusion, which are common issues for cognitively impaired patients.
Choice C rationale:
A room adjacent to the nursing station may not be the most therapeutic environment. While proximity to staff can be beneficial, the increased noise and activity level near the nursing station could be overstimulating and disruptive for a cognitively impaired client.
Choice D rationale:
A room with dim lighting is not ideal for a cognitively impaired client. Adequate lighting is important to help these patients maintain orientation and avoid falls or other safety issues. Dim lighting can contribute to confusion and disorientation.
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