A nurse is planning care for a male client who is postoperative following a hernia repair. Which of the following actions should the nurse include in the plan?
Elevate the client's scrotum on a pillow.
Restrict fluids to 1,200 mL per day.
Place a warm pack on the incisional area.
Encourage the client to sit to void.
The Correct Answer is A
Rationale:
A. Elevate the client's scrotum on a pillow: After hernia repair, scrotal elevation helps reduce swelling and promote venous return, minimizing postoperative edema and discomfort. Supporting the scrotum with a pillow or rolled towel also decreases tension on the incision site, enhancing comfort and healing.
B. Restrict fluids to 1,200 mL per day: Fluid restriction is not indicated for clients following hernia repair unless there is a concurrent condition such as renal or cardiac impairment. Adequate hydration is essential to prevent constipation and promote tissue recovery after surgery.
C. Place a warm pack on the incisional area: Warm packs should be avoided immediately after surgery because they can increase local blood flow and risk of bleeding at the incision site. Cold packs may be used instead to reduce swelling and provide comfort.
D. Encourage the client to sit to void: Male clients are encouraged to stand when voiding to reduce intra-abdominal pressure on the surgical site. Sitting to void may increase pressure on the repaired area, potentially causing discomfort or strain on the incision.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Obtaining the initial assessment of assigned clients: The initial assessment requires nursing judgment and clinical decision-making, which are within the scope of practice of a registered nurse only. It involves data interpretation and establishing a baseline for care, tasks that cannot be delegated to assistive personnel.
B. Educating a client and family members on home care: Client and family teaching requires specialized nursing knowledge to ensure understanding and accuracy. This task involves evaluating learning needs and reinforcing critical information, responsibilities that cannot be legally delegated to assistive personnel.
C. Changing a nonsterile dressing: Assistive personnel can safely perform nonsterile procedures such as changing a clean dressing under the supervision of a nurse. This task involves routine care that does not require nursing judgment, making it appropriate for delegation.
D. Interpreting a client's diagnostic laboratory results: Interpretation of laboratory data involves analysis, clinical reasoning, and the ability to make informed nursing decisions. These actions fall strictly within the nurse’s professional scope of practice and cannot be delegated to assistive personnel.
Correct Answer is A
Explanation
Rationale:
A. Establish alternatives to verbal conversation: Expressive aphasia affects a person’s ability to produce speech, so using alternative communication methods—such as picture boards, writing tools, or gestures—helps the client express needs effectively.
B. Provide educational materials with large print: Large-print materials are helpful for clients with visual impairments, not speech difficulties. Since expressive aphasia is a language production disorder, adjusting text size does not facilitate communication or address the underlying deficit.
C. Use a mechanical voice amplifier: A voice amplifier is beneficial for clients who can speak but have weak vocal strength, such as those with vocal cord paralysis. It is ineffective for clients with expressive aphasia because the issue lies in word formation, not vocal volume.
D. Have the client's glasses brought from home: Glasses improve visual acuity but do not address the client’s difficulty in forming words or sentences. While ensuring clear vision is supportive, it does not directly enhance the client’s ability to communicate verbally.
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