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 C

Explanation

A. Peeling of the hands and feet is not a common manifestation of pertussis. This symptom is typically associated with other conditions, such as Kawasaki disease or toxic shock syndrome, rather than an infection caused by Bordetella pertussis.
B. Beefy, red tongue is usually seen in conditions like scarlet fever or certain nutritional deficiencies, such as vitamin B12 deficiency. It is not characteristic of pertussis and does not align with the typical clinical presentation of this respiratory illness.
C. Fever is a common manifestation of pertussis, especially in the early stages. The child may present with a mild to moderate fever as the immune system responds to the infection. Fever can help in distinguishing pertussis from other respiratory illnesses, especially in conjunction with the classic coughing fits.
D. Facial erythema is not typically seen in pertussis. While some flushing may occur during intense coughing episodes, it is not a primary symptom. Pertussis is more characterized by severe coughing fits, the distinctive "whoop" sound during inspiration, and potential vomiting after coughing.

A. Confusion B. Abdominal cramps C. Positive Chvostek's sign D. Decreased bowel motility

Correct Answer is B

Explanation

A. Confusion can occur with electrolyte imbalances, including hyperkalemia, but it is not the most common or specific symptom associated with elevated potassium levels. More typical symptoms are related to muscle and gastrointestinal function.
B. Abdominal cramps are a common finding in clients with hyperkalemia (potassium level of 5.8 mEq/L). Elevated potassium can lead to increased gastrointestinal motility and irritability, resulting in symptoms such as abdominal cramps and diarrhea.
C. Positive Chvostek's sign indicates hypocalcemia (low calcium levels) and is not associated with hyperkalemia. This sign reflects increased neuromuscular excitability due to low calcium levels, so it would not be expected in this scenario.
D. Decreased bowel motility is typically associated with hypokalemia (low potassium levels) rather than hyperkalemia. Elevated potassium levels can cause increased bowel motility and may lead to gastrointestinal symptoms like diarrhea and cramping. Therefore, decreased bowel motility would not be an expected finding in this case.

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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 collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?

Correct Answer is C

Explanation

A nurse in a long-term care facility is reviewing a client's laboratory results. The client's potassium level is 5.8 mEq/L (3.5 to 5 mEq/L). Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

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Exhibits

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