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A nurse removes a client's Foley catheter and documents that the client urinates 4 hours later. Which of the following elements of postoperative care is the nurse performing?

Providing surgical site or wound care

Managing postoperative pain

Assisting with early ambulation

Monitoring urinary function

Answer and Explanation

The Correct Answer is D

Choice A reason: The nurse is not providing surgical site or wound care by documenting urination.

Choice B reason: Managing postoperative pain is not directly related to monitoring the client's ability to urinate.

Choice C reason: Assisting with early ambulation does not pertain to the urinary function directly.

Choice D reason: Monitoring urinary function is part of postoperative care, especially after removal of a Foley catheter, to ensure the client is able to void normally.

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Correct Answer is ["A","C","D","E"]

Explanation

Choice A reason: Pruritus, or severe itching, is a common symptom in patients with ESRD due to the build-up of waste products in the body.

Choice B reason: Slurred speech is not typically associated with ESRD. It may be a symptom of other neurological conditions or could be related to medications or treatments.

Choice C reason: Hypotension can be an expected finding in ESRD due to the fluid shifts and changes in blood volume

that occur during dialysis treatment.

Choice D reason: Bone pain is a known complication of ESRD, often resulting from the mineral and bone disorders that are part of chronic kidney disease-mineral and bone disorder (CKD-MBD).

Choice E reason: Bradypnea, or abnormally slow breathing, may occur in ESRD as a result of metabolic changes affecting the respiratory system.

A. Headache, restlessness B. Decreased blood pressure, rapid pulse C. Muscle cramps, chest heaviness D. Pain and tingling at the access site

Correct Answer is A

Explanation

The correct answer is Choice A

Choice A rationale: Headache and restlessness can be signs of a seizure or neurological disturbance, which phenytoin is used to treat. Phenytoin is an anticonvulsant medication that helps control seizures by stabilizing neuronal membranes and reducing excitability.

Choice B rationale: Decreased blood pressure and rapid pulse are not indications for phenytoin administration. These symptoms may suggest hypotension or cardiovascular issues, which require different interventions such as fluid resuscitation or vasopressors.

Choice C rationale: Muscle cramps and chest heaviness are not treated with phenytoin. These symptoms could indicate electrolyte imbalances or cardiac issues, which need specific treatments like electrolyte replacement or cardiac monitoring.

Choice D rationale: Pain and tingling at the access site are not indications for phenytoin administration. These symptoms may suggest local irritation or infection at the dialysis access site, requiring appropriate wound care or antibiotics.

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A nurse removes a client's Foley catheter and documents that the client urinates 4 hours later. Which of the following elements of postoperative care is the nurse performing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has end-stage renal disease (ESRD). Which of the following are expected findings? (Select all that apply).

Correct Answer is ["A","C","D","E"]

Explanation

A nurse is caring for a client immediately following a hemodialysis treatment. For which of the following manifestations will the nurse administer a PRN dose of phenytoin?

Correct Answer is A

Explanation

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