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 D
Explanation
Rationale:
A. "Dehydration is caused by a decreased hemoglobin and hematocrit.": Dehydration typically results in increased, not decreased, hemoglobin and hematocrit values because fluid loss concentrates red blood cells. Low values would suggest anemia or blood loss rather than dehydration.
B. "Dehydration is associated with gastroesophageal reflux.": While dehydration may worsen nausea or fatigue, it is not directly linked to gastroesophageal reflux. GERD in pregnancy is usually caused by hormonal relaxation of the lower esophageal sphincter and increased intra-abdominal pressure from the enlarging uterus.
C. "Dehydration is treated with calcium supplements.": Calcium supplements are unrelated to treating dehydration. Management focuses on restoring fluid balance through oral or intravenous hydration to maintain uteroplacental perfusion and reduce uterine irritability.
D. "Dehydration can increase the risk for preterm labor.": Dehydration leads to increased secretion of antidiuretic hormone (ADH), which can stimulate oxytocin release and uterine contractions. Correcting dehydration helps reduce uterine activity and lowers the risk of preterm labor in pregnant clients.
Correct Answer is D
Explanation
Rationale:
A. Prolonged QT interval: Morphine does not typically cause a prolonged QT interval. QT prolongation is more commonly associated with certain antiarrhythmic or psychotropic medications, not opioid toxicity.
B. Fluid retention: Morphine is not known to cause fluid retention. Signs of toxicity are primarily related to central nervous system and respiratory depression rather than cardiovascular fluid balance.
C. Hyperactive deep tendon reflexes: Morphine toxicity usually depresses neurological function, leading to decreased reflexes rather than hyperactivity. Hyperactive reflexes are not characteristic of opioid overdose.
D. Bradypnea: Respiratory depression, manifested as bradypnea, is a hallmark sign of morphine toxicity. Excessive morphine depresses the brainstem respiratory centers, reducing the rate and depth of respirations, which can be life-threatening if not addressed promptly.
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