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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

Rationale:

• Deep tendon patellar reflex: The reflex response decreased from 4+ to 2+, demonstrating a reduction in hyperreflexia. This improvement indicates effective magnesium sulfate therapy, showing decreased neuromuscular irritability and a lower risk of progression to eclampsia.

• Blood pressure: The blood pressure declined from 166/110 mm Hg to 152/90 mm Hg, reflecting effective antihypertensive therapy and improved vascular tone. This moderate reduction suggests that labetalol and magnesium sulfate are successfully controlling severe preeclampsia symptoms.

• Heart rate: The heart rate remained within normal parameters (72–90/min) across both days, showing stable cardiac function without significant deviation. This consistency indicates no notable change in hemodynamic status related to treatment.

• Edema: The client continues to exhibit +3 pitting edema in both lower extremities, reflecting persistent fluid retention and endothelial dysfunction. This ongoing finding suggests that intravascular fluid shifts typical of preeclampsia have not yet resolved.

A. Gently push the syringe plunger to administer medication. B. Dissolve the medications together. C. Flush the NG tube with 5 mL of cold tap water after administration. D. Add medication directly to the enteral feeding.

Correct Answer is A

Explanation

Rationale:
A. Gently push the syringe plunger to administer medication: Medications given via NG tube should be administered slowly and gently using a syringe to avoid tube damage, aspiration, or sudden changes in gastric pressure. This technique ensures safe and effective delivery of the medication.

B. Dissolve the medications together: Mixing multiple medications can cause chemical interactions or precipitation, which can block the NG tube or reduce medication efficacy. Each medication should be dissolved and administered separately.

C. Flush the NG tube with 5 mL of cold tap water after administration: Flushing is necessary to maintain tube patency, but 5 mL is insufficient for continuous feedings. Typically, 15–30 mL of warm or room-temperature water is used to prevent tube occlusion.

D. Add medication directly to the enteral feeding: Adding medication to the feeding can alter the composition, affect absorption, and create a risk for tube blockage. Medications should be given separately with flushing before and after administration.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

A nurse is preparing to administer three medications to a client who is receiving continuous enteral feedings through an NG tube. Which of the following actions is appropriate for the nurse to take?

Correct Answer is A

Explanation

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