Exhibits

Select the 2 actions the nurse should prepare to take for the client.

Encourage oral fluid intake.

Administer an enema.

Irrigate indwelling catheter with 500 mL of fluid.

Assist the client with a sitz bath.

Encourage prolonged dangling before ambulation.

Answer and Explanation

Correct Answer : A,B

A. Encourage oral fluid intake. The client has pink urine, which may indicate mild hematuria. While the urine output is adequate, increasing fluid intake can help dilute the urine, reduce irritation, and promote overall hydration. Additionally, increased fluid intake can aid in softening stool and preventing further constipation.
B. Administer an enema. The client reports abdominal cramping and a small, hard, painful bowel movement, indicating constipation. Postoperative clients are at risk for constipation due to decreased mobility, opioid pain medications, and anesthesia effects. Administering an enema can help relieve discomfort and promote bowel movements.
C. Irrigate indwelling catheter with 500 mL of fluid. The client's urinary catheter is intact, and there is a consistent urine output of 100 mL/hr. The presence of pink urine does not indicate obstruction requiring catheter irrigation. Irrigation with such a large volume could introduce unnecessary risk and is not warranted at this time.
D. Assist the client with a sitz bath. Sitz baths are typically used for perineal discomfort, such as after perineal surgery, hemorrhoids, or childbirth. There is no indication in the nurse’s notes that the client has perineal pain or a condition requiring a sitz bath.
E. Encourage prolonged dangling before ambulation. The client is already ambulating independently, indicating no significant issues with orthostatic hypotension or weakness. Encouraging prolonged dangling is unnecessary and could delay mobility, which is essential for preventing complications such as constipation and venous thromboembolism.

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Correct Answer is A

Explanation

A. Inject 15 units of air into the regular insulin vial. When mixing NPH and regular insulin, air is first injected into both vials without touching the solution. After injecting air into the NPH vial, the next step is to inject air into the regular insulin vial to maintain proper vial pressure before withdrawing the dose.
B. Place the cap over the needle. Recapping needles increases the risk of needlestick injuries and is not necessary during the insulin preparation process. The needle should remain uncapped until both insulins are drawn and the injection is ready.
C. Withdraw 10 units of NPH insulin. Regular insulin should be drawn first to prevent contamination with NPH insulin. Since NPH is a cloudy suspension and regular insulin is clear, drawing regular insulin first ensures that the short-acting insulin remains unaltered.
D. Verify the dosage with another nurse. While verifying high-risk medications like insulin is important, the appropriate step after injecting air into the NPH vial is to proceed with injecting air into the regular insulin vial before withdrawing any insulin.

A. Difficulty swallowing B. Constipation C. Urinary retention D. Clenched teeth

Correct Answer is D

Explanation

A. Difficulty swallowing. While difficulty swallowing (dysphagia) can be associated with certain conditions, it is not a typical indicator of unrelieved pain in a client receiving a spinal epidural. This symptom may be related to neurological involvement or medication side effects and should be assessed further.
B. Constipation. Opioids used in conjunction with epidural anesthesia can contribute to constipation, but this is a side effect rather than a direct indicator of pain. Constipation can also result from reduced mobility or decreased fluid intake, so it should be managed appropriately but does not necessarily reflect uncontrolled pain.
C. Urinary retention. Epidural anesthesia can affect bladder function by impairing the sensation of fullness and the ability to void. While urinary retention is a common side effect of epidural use, it is not a direct sign of unrelieved pain. Monitoring for bladder distention and assessing for the need for catheterization is important.
D. Clenched teeth. Clenching the teeth is a physical manifestation of pain, often indicating discomfort and distress. Clients experiencing unrelieved pain may also exhibit other nonverbal cues such as grimacing, restlessness, or guarding. The nurse should assess pain using an appropriate scale and notify the provider if pain is not adequately controlled.

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Exhibits Select the 2 actions the nurse should prepare to take for the client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next?

Correct Answer is A

Explanation

A nurse is assisting with the care of a client who is receiving a spinal epidural to treat a herniated disc. Which of the following findings should the nurse identify as an indicator of unrelieved pain?

Correct Answer is D

Explanation

A nurse is reviewing client confidentiality with other staff members. The nurse should identify that which of the following actions is an example of protecting client confidentiality?

A nurse in a provider's office is caring for a group of clients who have communicable diseases. Which of the following infections should the nurse report to the state health department?

A nurse is providing site care for a child who has a gastrostomy enteral tube. Which of the following actions should the nurse take?

A nurse is supervising an assistive personnel (AP) who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene?

A nurse is reinforcing teaching with a client who is postpartum about keeping her newborn safe while in the facility. Which of the following Instructions should the nurse include in the teaching?

A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?

A nurse is caring for a client who is taking multiple medications and asks about possible interactions. To which of the following members of the interdisciplinary team should the nurse make a referral?

Exhibits

Select the 2 actions the nurse should prepare to take for the client.