Nurses' Notes.

Postoperative Day 3. 0900: Client reports pain at surgical incision site as 5 on a scale of 0 to. 10. Client reports bladder fullness.

Perineal dressing intact with minimal serosanguinous drainage.

Client transferring out of bed to chair independently.

Extremities cool and dry with 2+. peripheral pulses.

1300: Client reports abdominal cramping and small, hard, painful bowel movement after lunch.

Ambulating independently in. hallway.

Reports pain as 8 on a scale ofO to 10. Urinary catheter intact with 100 mL/hr of pink urine.

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

Administer an enema.

Assist the client with a sitz bath.

Irrigate indwelling catheter with 500 mL of fluid.

Encourage prolonged dangling before ambulation.

Encourage oral fluid intake.

Answer and Explanation

Correct Answer : A,E

Choice A rationale:

Administering an enema can help relieve the client’s abdominal cramping and small, hard, painful bowel movement. An enema is a procedure that involves introducing a liquid solution into the rectum to promote evacuation of feces. It can be used to relieve constipation, which seems to be the client’s issue based on the description of their bowel movement.

Choice B rationale:

Assisting the client with a sitz bath may not be necessary at this time. A sitz bath is typically used to soothe and cleanse the perineal area, particularly after childbirth or surgery. While the client does have a surgical incision, the notes indicate that the perineal dressing is intact with minimal serosanguinous drainage, suggesting that the incision site is not currently problematic.

Choice C rationale:

Irrigating an indwelling catheter with 500 mL of fluid is not recommended unless there is a specific indication, such as the catheter being blocked. The client’s urinary catheter is intact with 100 mL/hr of pink urine, which suggests that it is functioning properly.

Choice D rationale:

Encouraging prolonged dangling before ambulation may not be beneficial for this client. Dangling involves sitting on the edge of the bed with legs hanging down before standing up. This can help prevent dizziness upon standing. However, the notes indicate that the client is already ambulating independently in the hallway, suggesting that they do not have issues with mobility or dizziness.

Choice E rationale:

Encouraging oral fluid intake can help alleviate constipation by softening stools and promoting bowel movements. It can also help maintain hydration, which is particularly important for postoperative clients. Therefore, this would be a beneficial action for the nurse to take for this client.

Nursing Test Bank

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Correct Answer is C

Explanation

Choice A rationale:

Inquiring about a family history of suicide is relevant but not the priority when a client is actively expressing suicidal ideations. Assessing the client's immediate risk and intent is more critical.

Choice B rationale:

Understanding the stresses in the client's life is important, but asking about a plan for self-harm takes precedence in assessing the client's immediate danger.

Choice C rationale:

This question directly addresses the client's intent and plan for self-harm. Identifying a plan is crucial in assessing the level of risk and determining the appropriate intervention.

Choice D rationale:

While having someone to discuss feelings with is important, it is not the primary concern when a client is expressing suicidal ideations. Assessing the client's immediate risk and plan for self-harm should come first.

A. Apply fundal pressure during contractions. B. Encourage the client to soak in a hot bath. C. Instruct the client to change positions frequently. D. Tell the client to push during contractions.

Correct Answer is C

Explanation

Choice A rationale:

"Apply fundal pressure during contractions." - Applying fundal pressure during contractions is not appropriate during the latent stage of labor. Fundal pressure is typically used during the second stage of labor (active pushing phase) to assist with fetal descent. Using it during the latent stage can be harmful.

Choice B rationale:

"Encourage the client to soak in a hot bath." - Soaking in a hot bath is generally not recommended during labor, especially without specific indications. It is essential to maintain the safety and well-being of both the mother and the baby. Encouraging the client to change positions or use comfort measures like relaxation techniques would be more appropriate.

Choice C rationale:

"Instruct the client to change positions frequently." - This is the correct answer. During the latent stage of labor, encouraging the client to change positions frequently can help promote comfort and optimize fetal positioning. Changing positions can reduce discomfort, enhance uterine contractions, and facilitate the progression of labor.

Choice D rationale:

"Tell the client to push during contractions." - Pushing during contractions is typically reserved for the second stage of labor when the cervix is fully dilated. In the latent stage, the cervix is not fully dilated, and pushing prematurely can be harmful and delay labor progress. It is essential to follow the appropriate guidelines for each stage of labor.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is C

Explanation

A nurse is assisting with the care of a client who is in the latent stage of labor and has pelvic pain with contractions.Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse in an acute care setting is preparing to administer medications to a client. Which of the following information should the nurse obtain to identify the client?

A nurse is discussing the plan of care of a client who is 4 hr postoperative and has a urostomy with an assistive personnel. Which of the following statements should the nurse include in the discussion?

A nurse is preparing to administer carbamazepine suspension 150 mg via NG tube every 6 hr. The amount available is 100 mg/5 mL. How many mL should the nurse administer with each dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse in a provider's office is collecting data from a client who has psoriasis. Which of the following statements by the client should the nurse report to the provider?

A nurse is caring for a client who has hypoglycemia.The nurse should monitor the client for which of the following adverse effects of hypoglycemia?

A nurse is caring for a client who has a prescription for levothyroxine.Which of the following laboratory tests should the nurse monitor?

A nurse is reinforcing discharge teaching with the caregiver of a client who has dependent personality disorder.Which of the following instructions should the nurse include in the teaching?