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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Ask the facility chaplain to visit the client. While spiritual support can be beneficial, the nurse should first acknowledge and respect the client’s decision. Offering a chaplain visit without the client's request may not align with their personal beliefs or needs.
B. Discuss alternative treatment methods with the client. End-stage kidney disease has limited treatment options beyond dialysis or kidney transplantation. If the client has already decided to stop dialysis, discussing alternatives may not be appropriate unless the client expresses interest. The priority is to support their decision and provide comfort-focused care.
C. Tell the client she should discuss this decision with her family. While family involvement can be helpful, the decision to continue or stop dialysis is ultimately the client’s right. Encouraging discussion is appropriate, but the nurse should not imply that the client must consult others before making a personal healthcare decision.
D. Support the client's decision to stop the treatment. Autonomy is a fundamental ethical principle in nursing. Clients have the right to make their own healthcare decisions, including the choice to discontinue dialysis. The nurse should offer emotional support, provide palliative care options, and ensure the client’s comfort during the transition.
Correct Answer is B
Explanation
A. "The website was last updated 3 years ago." Medical information evolves rapidly, and outdated sources may contain inaccurate or obsolete data. Regular updates improve credibility.
B. "The author cites references to statements made." Citing references supports the accuracy and credibility of medical information. Reliable sources should provide evidence-based content backed by research or reputable organizations.
C. "The website URL is listed as .com." Commercial websites (.com) can contain valid information, but they may also prioritize marketing over accuracy. Government (.gov), educational (.edu), and nonprofit (.org) sites tend to be more reliable.
D. "The author's name is listed without credentials." Without credentials, it is difficult to verify the author's expertise. Reliable medical sources should have content written or reviewed by professionals with relevant qualifications.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.