Exhibits

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

A. "I will get you information about some head-covering options." This response is supportive and addresses the client's concerns about hair loss in a practical way. Providing information about head coverings, such as hats, scarves, or wigs, can help the client feel more prepared and empowered to manage this aspect of their treatment.
B. "I wouldn't worry about this right now. Let's focus on your chemotherapy." Dismissing the client's concerns may make them feel invalidated. Hair loss can be a significant emotional issue for many clients undergoing chemotherapy, and it’s important to address their feelings and provide support.
C. "Let's discuss this when we have more time." Postponing the conversation may leave the client feeling anxious or unsupported. Clients may need immediate reassurance and resources regarding their concerns, so it is essential to address it in a timely manner.
D. "I can't imagine how difficult it would be to lose my hair." Expressing empathy is important, but shifting the focus to the nurse's feelings rather than addressing the client's concerns is not helpful. It is more beneficial to provide practical support and resources to help the client cope with potential hair loss.

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.