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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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A,C"}}

Explanation

Urticaria: Present in latex allergy, as hypersensitivity reactions to latex can cause pruritic hives due to histamine release.
Hypercapnia: Present in malignant hyperthermia, as it results from uncontrolled skeletal muscle contractions leading to excessive carbon dioxide production.
Wheezes: Present in latex allergy due to bronchoconstriction and airway hypersensitivity, which can lead to respiratory distress.
Muscle rigidity: Present in malignant hyperthermia, as sustained muscle contractions occur due to excessive calcium release in skeletal muscles.
Tachycardia: Present in both malignant hyperthermia and hypovolemic shock. Malignant hyperthermia causes tachycardia due to increased metabolic activity and hypercapnia, while hypovolemic shock results in tachycardia as a compensatory mechanism for reduced circulating volume.

A. Nausea B. Hand tremors C. Hyperglycemia D. Shortness of breath

Correct Answer is D

Explanation

A. Nausea. Epinephrine is not primarily used to treat nausea. It is a sympathomimetic medication that works by stimulating alpha and beta receptors, mainly to counteract severe allergic reactions, including respiratory distress and hypotension. Nausea is not a primary indication for its use.
B. Hand tremors. Epinephrine can cause hand tremors as a side effect due to its stimulant effects on the nervous system. However, it is not used to treat tremors, and the presence of tremors after administration is a common physiological response rather than a therapeutic effect.
C. Hyperglycemia. Epinephrine can increase blood glucose levels by stimulating glycogenolysis and inhibiting insulin secretion. However, it is not used for treating hyperglycemia, and its effects on glucose metabolism are incidental rather than a primary therapeutic action.
D. Shortness of breath. Epinephrine is commonly used to treat anaphylaxis, which can cause airway swelling and bronchospasm leading to shortness of breath. By stimulating beta-2 receptors, epinephrine relaxes bronchial smooth muscles, improving airflow and reducing respiratory distress.

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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 assisting with the care of a client. Exhibits For each data collection finding click to specify if the finding corresponds to malignant hyperthermia, latex allergy or hypovolemic shock. Each finding may be related to more than 1 option.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A,C"}}

Explanation

A nurse is reinforcing teaching with a client who has a new prescription for epinephrine auto-injector PRN. The nurse should reinforce with the client that the medication can help treat which of the following manifestations?

Correct Answer is D

Explanation

A nurse is collecting data from a client who is expressing suicidal ideations. Which of the following questions is the nurse's priority?

A nurse is assisting with the care of a client who is experiencing postpartum hemorrhage. Which of the following medications could the nurse administer to the client via the sublingual or rectal route?

A nurse is collecting data from a client who has thrombocytopenia. The nurse should identify that which of the following findings increases the client's risk for injury?

A nurse is assisting in the care of a newly admitted client. Exhibits Which of the following findings should the nurse report immédiately to the provider?Select all that apply.

A nurse is contributing to the plan of care for a client who has major depressive disorder. Which of the following recommendations should the nurse include in the plan of care?

A nurse is assisting with preparing a client who is to have a central venous catheter inserted for the administration of total parenteral nutrition (TPN). Which of the following actions should the nurse take?

A nurse is verifying informed consent for a client who is preoperative for a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent?

A nurse is monitoring a client who was admitted for hypocalcemia. Which of the following findings should the nurse expect?

Exhibits

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