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 ["A","D","E"]
Explanation
Rationale:
A. Assess the client's lung sounds prior to the infusion: Baseline lung assessment helps detect early signs of fluid overload or transfusion-associated circulatory overload (TACO), which is especially important in older adults.
B. Prime the infusion tubing with 0.45% sodium chloride: Only 0.9% sodium chloride (normal saline) is compatible with blood products. Hypotonic solutions such as 0.45% sodium chloride can cause hemolysis of red blood cells.
C. Don sterile gloves to prepare the blood administration setup: Clean gloves are sufficient for preparing and administering blood transfusions. Sterile gloves are not required unless performing a sterile procedure.
D. Verify with another nurse that the unit of blood is compatible with the client's blood type: Double verification of the client’s identity and blood compatibility prevents hemolytic transfusion reactions due to mismatched blood.
E. Infuse the blood over 4 hr: Each unit of packed RBCs should be transfused within no more than 4 hours to reduce the risk of bacterial contamination and hemolysis from prolonged infusion.
Correct Answer is B
Explanation
Rationale:
A. "Can you tell me more about the surgery I am having?": Before signing consent, the client should already have received complete information about the nature, purpose, risks, and benefits of the surgery from the provider.
B. "Signing this form indicates that I give my permission for the surgery, right?": Informed consent is a legal and ethical document granting permission for the procedure. It shows that the client comprehends their role in authorizing the surgery after receiving adequate information from the healthcare provider.
C. "I will talk with the doctor about my surgery when I get into the operating room.": Consent discussions should occur before entering the operating room. The client must have all questions answered and sign consent prior to sedation or anesthesia to ensure voluntary decision-making.
D. "Every so often, I think about whether or not to have this surgery.": This response suggests indecision and lack of informed readiness for the procedure. The nurse must notify the provider so further discussion can occur to address concerns and ensure the client’s consent is fully informed and voluntary.
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