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 C
Explanation
This is because potassium is a medication that can cause cardiac arrest if given too quickly or in high doses. A nurse who administers potassium via IV bolus is not providing the standard of care that a similarly trained nurse would have offered under the same circumstances. This could result in harm or death to the patient.
Choice A is wrong because placing a yellow bracelet on a client who is at risk for falls is not malpractice, but rather a safety measure.
A yellow bracelet indicates that the client needs assistance with mobility and should not be left alone. This is a common practice in many health care facilities to prevent falls and injuries.
Choice B is wrong because leaving a nasogastric tube clamped after administering oral medication is not malpractice, but rather a mistake.
A nasogastric tube is a tube that goes through the nose and into the stomach to deliver nutrition or medication.
It should be unclamped after giving oral medication to allow the medication to enter the stomach and prevent reflux or aspiration. However, this error does not rise to the level of malpractice unless it causes harm to the patient, such as vomiting, choking, or infection.
Choice D is wrong because documenting communication with a provider in the progress notes of the client’s medical record is not malpractice, but rather a good practice.
Correct Answer is B
Explanation
The correct answer is choice b. Using an electronic messaging system to remind clients when to take medications.
Choice A rationale:
Educating clients about contraindications to specific immunizations is an example of primary prevention, which aims to prevent disease before it occurs.
Choice B rationale:
Using an electronic messaging system to remind clients when to take medications is an example of tertiary prevention. It helps manage an existing condition (HIV) by ensuring adherence to treatment, thereby preventing complications and improving quality of life.
Choice C rationale:
Providing clients with information about the benefits of exercise is generally considered primary prevention, as it aims to promote overall health and prevent disease.
Choice D rationale:
Helping clients understand health screenings covered by their insurance plans is an example of secondary prevention, which focuses on early detection and treatment of disease.
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