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 {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Endoscopy is the most appropriate diagnostic tool to visualize the gastrointestinal tract directly when gastrointestinal bleeding is suspected. Given the client’s symptoms of gnawing abdominal pain, radiation of pain to the back, and a positive Hemoccult stool test Endoscopy will help confirm this diagnosis and allow for appropriate treatment.
Positive Hemoccult stool indicates the presence of occult blood, which is a hallmark sign of gastrointestinal bleeding. In this case, the presence of blood in the stool aligns with the client’s symptoms of abdominal pain and possible peptic ulcer disease, often linked with H. pylori infection. The positive Hemoccult stool test justifies the need for endoscopy to identify the source of bleeding and guide further management.

Barium swallow. A barium swallow can detect structural abnormalities like strictures, tumors, or achalasia in the esophagus but is not as effective as endoscopy in diagnosing peptic ulcers or evaluating gastrointestinal bleeding. In this case, endoscopy is the preferred diagnostic method as it provides direct visualization of ulcers or other lesions in the stomach or duodenum.
CT scan. While a CT scan can be helpful in assessing for abdominal issues like perforation or obstruction, it is not the first choice for diagnosing peptic ulcers or gastrointestinal bleeding. Endoscopy provides a more targeted and effective approach for visualizing the gastrointestinal tract and identifying the source of the bleeding.
Surgical intervention.Surgical intervention is typically reserved for severe cases where there is gastrointestinal perforation or uncontrollable bleeding. In this case, the client has not yet shown signs of perforation or hemorrhagic shock that would require immediate surgery. Initial diagnostic tests, such as endoscopy, are needed before surgical consideration.

WBC count of 6,700/mm³. The client’s WBC count is within the normal range (5,000 to 10,000/mm³), suggesting no current acute infection. While inflammation could be indicated in cases of ulcers or gastritis, the normal WBC count in this case does not raise immediate concern for infection. It is unlikely to directly influence the need for endoscopy, which is guided primarily by the clinical presentation and positive Hemoccult stool result.

Hemoglobin of 9.1 g/dL, Hematocrit of 27%. The low hemoglobin and hematocrit levels indicate anemia, which is often caused by chronic blood loss. This aligns with the positive Hemoccult stool test, which suggests that the client is losing blood through the gastrointestinal tract, possibly due to a peptic ulcer. This finding supports the need for endoscopy to investigate the cause of the bleeding and assess the need for treatment such as blood transfusions or iron supplementation.

A. Understands that everyone dies eventually B. Expresses curiosity about the funeral service C. Believes the death is punishment for bad behavior D. Recognizes the parent will never wake up

Correct Answer is C

Explanation

A. "Understands that everyone dies eventually." Preschoolers typically do not have a comprehensive understanding of the concept of death and its universality. Their grasp of death is often more concrete, focusing on the specific situation rather than a general concept.
B. "Expresses curiosity about the funeral service." While some preschoolers may show curiosity about the funeral service, many might find the concept of a funeral confusing. Their understanding of death is often limited, and they may not ask questions about such abstract concepts.
C. "Believes the death is punishment for bad behavior." Preschoolers often have egocentric thinking and may associate events with their own actions, leading them to believe that a parent's death is a form of punishment for their behavior. This is a common response in this age group as they struggle to comprehend death and its causes.
D. "Recognizes the parent will never wake up." Preschoolers typically do not fully grasp the permanence of death. They may believe that the deceased parent will wake up or return, reflecting their limited understanding of the finality of death.

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

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who is admitted to the medical-surgical unit. Exhibits Complete the following sentence by using the lists of options. The nurse anticipates the client will likely require dropdownas evidenced by the client'sdropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

A nurse is caring for a preschooler who recently experienced the death of a parent. Which of the following findings should the nurse identify as consistent with this age group?

Correct Answer is C

Explanation

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Exhibits

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