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 B

Explanation

A. Postoperative ambulation is important for recovery and preventing complications such as deep vein thrombosis, but it is not the most critical focus in the immediate preoperative period for a client undergoing a total laryngectomy.
B. Stoma site cleaning is the priority for the nurse to reinforce. After a total laryngectomy, the client will have a permanent stoma (opening) in the neck for breathing. Proper care and cleaning of the stoma site are essential to prevent infection, maintain airway patency, and ensure the client can manage their new method of breathing effectively.
C. Pain management is an important aspect of postoperative care, but it is secondary to ensuring that the client understands how to care for their stoma. Addressing pain is essential for comfort, but it does not take precedence over the immediate care required for the stoma.
D. Coughing and deep breathing are important for maintaining lung function and preventing complications such as pneumonia after surgery, but they are not the most critical teaching point for a client who will have a stoma after a total laryngectomy. The priority should be on the specific care of the stoma to ensure safety and effective breathing postoperatively.

A. Administer aspirin for pain. B. Apply an ice pack to the effected extremity for 20 min every 2 hr. C. Massage the affected extremity every 4 hr. D. Initiate bed rest.

Correct Answer is D

Explanation

A. Administer aspirin for pain. Aspirin is an antiplatelet medication and is not appropriate for managing pain in a client with deep vein thrombosis (DVT). Additionally, aspirin can increase the risk of bleeding, especially in clients receiving anticoagulant therapy, so it should be avoided in this context.
B. Apply an ice pack to the affected extremity for 20 min every 2 hr. While ice packs may be helpful in reducing swelling, applying ice is generally not recommended for DVT because it may cause vasoconstriction and increase the risk of thrombosis. It’s more important to follow appropriate medical treatment guidelines for DVT management.
C. Massage the affected extremity every 4 hr. Massaging the affected extremity is contraindicated in cases of DVT, as it can dislodge the thrombus, potentially leading to a pulmonary embolism or other serious complications.
D. Initiate bed rest. Initiating bed rest is the appropriate action for a client with DVT. Bed rest helps prevent further clot formation and reduces the risk of complications. The healthcare provider will also typically order anticoagulant therapy to manage the condition safely. The client should avoid movement of the affected leg until medically advised otherwise.

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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 reinforcing preoperative teaching with a client who is scheduled for a total laryngectomy. Which of the following information is the priority for the nurse to reinforce?

Correct Answer is B

Explanation

A nurse is caring for a client who is 12 hr postpartum and has deep-vein thrombosis of the left leg. The client is receiving anticoagulant therapy. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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Exhibits

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