A nurse is caring for a postoperative client following a perineal prostatectomy.
For each potential provider’s prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.
Potential Order:.
Apply warm compresses to the incision site.
Maintain bed rest for 2 days postoperatively.
Irrigate indwelling urinary catheter with 50 mL of normal saline.
Administer enema to relieve constipation.
Place a blanket roll under the client’s knees while in bed.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"B"}}
The correct answer is choice A. Applying warm compresses to the incision site is anticipated for the client, as it can help reduce swelling and pain.
The other choices are contraindicated for the following reasons:
- Choice B: Maintaining bed rest for 2 days postoperatively is contraindicated, as it can increase the risk of complications such as deep vein thrombosis, pulmonary embolism, and pneumonia. The client should be encouraged to ambulate as soon as possible after surgery.
- Choice C: Irrigating indwelling urinary catheter with 50 mL of normal saline is contraindicated, as it can introduce bacteria into the bladder and cause infection. The catheter should be kept patent and draining without irrigation unless there is a specific order from the provider.
- Choice D: Administering enema to relieve constipation is contraindicated, as it can increase the pressure in the pelvic area and cause bleeding or damage to the surgical site. The client should be given stool softeners and laxatives to prevent constipation.
- Choice E: Placing a blanket roll under the client’s knees while in bed is contraindicated, as it can impair blood circulation and cause thrombophlebitis. The client should avoid flexing the knees excessively and elevate the legs slightly when lying down.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Furosemide is a loop diuretic that is used to treat fluid volume excess by increasing the excretion of water and electrolytes through the kidneys. Weight loss is an indication that the medication has been effective in reducing the excess fluid in the body.
Choice B is wrong because decreased inflammation is not a direct effect of furosemide.
Inflammation is a response to tissue injury or infection, and furosemide does not have any anti-inflammatory properties.
Choice C is wrong because increased blood pressure is not an indication of furosemide effectiveness.
Furosemide lowers blood pressure by reducing the preload and afterload on the heart.
Increased blood pressure may indicate that the dose of furosemide is insufficient or that there are other factors contributing to hypertension.
Choice D is wrong because decreased pain is not an expected outcome of furosemide therapy.
Furosemide does not have any analgesic effects, and pain may be caused by various conditions that are not related to fluid volume excess.
Normal ranges for weight, blood pressure, and pain vary depending on the individual patient’s baseline and goals.
However, some general guidelines are:
• Weight: A weight loss of 0.5 to 1 kg per day is considered safe and effective for patients with fluid volume excess.
• Blood pressure: The target blood pressure for most patients with heart failure is less than 130/80 mmHg.
• Pain: The pain level should be assessed using a valid and reliable scale, such as the numeric rating scale or the visual analog scale, and treated according to the patient’s preference and tolerance.
Correct Answer is D
Explanation
This is because abruptly stopping TPN can cause hypoglycemia, which is a low blood sugar level that can cause shakiness, diaphoresis, confusion, and seizures. Therefore, infusing dextrose 10% in water temporarily at the same rate as the TPN can prevent this adverse effect. Dextrose 10% in water is a hypertonic solution that contains 340 calories per liter and can maintain the client’s blood glucose level until the new TPN bag arrives.
Choice A is wrong because giving 500 mL of lactated Ringer’s solution would not provide enough calories or glucose to prevent hypoglycemia. Lactated Ringer’s solution is an isotonic solution that contains electrolytes but no calories or glucose.
Choice B is wrong because temporarily discontinuing the infusion would cause hypoglycemia, which can be life-threatening for the client.
Choice C is wrong because slowing the TPN infusion rate would also cause hypoglycemia, as the client would receive less calories and glucose than prescribed.
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