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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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Choice A rationale:

The nurse should not include the instruction to "Avoid breastfeeding for 3 days after receiving the vaccine." This is not a necessary precaution for the MMR vaccine. Breastfeeding can continue after the MMR vaccination without any adverse effects on the infant.

Choice B rationale:

The correct instruction is to "Avoid pregnancy for at least 28 days after receiving the vaccine." This is because the MMR vaccine is a live attenuated vaccine, and there is a theoretical risk of transmitting the virus to a developing fetus. Waiting for 28 days after vaccination allows the woman's immune system to respond to the vaccine and reduce any potential risk to the fetus. This is especially important during the postpartum period when a woman may be at risk of becoming pregnant again.

Choice C rationale:

The statement "If you are allergic to gluten, you should not receive this vaccine" is not accurate. The MMR vaccine does not contain gluten as an ingredient. Allergic reactions to the MMR vaccine are generally related to components of the vaccine itself, not gluten.

Choice D rationale:

The instruction to "Your partner should also receive the MMR vaccine" is not a standard recommendation for postpartum women. While it is essential for individuals to be up-to-date on their vaccinations, the focus in this scenario should be on the postpartum woman receiving the MMR vaccine to protect herself and any future pregnancies.

A. "We require informed consent for all routine treatments.” B. "You can sign the informed consent form after the provider explains the pros and cons of the procedure.” C. "We can accept verbal consent unless the surgical procedure is an emergency.” D. "A family member must witness your signature on the informed consent form.”

Correct Answer is B

Explanation

Choice A rationale:

The statement that "we require informed consent for all routine treatments" is not accurate. Informed consent is typically required for procedures and treatments that carry significant risks or require the patient's understanding and agreement. Routine treatments such as taking vital signs or administering routine medications do not typically require informed consent.

Choice B rationale:

The nurse should include in the teaching that the client can sign the informed consent form after the provider explains the pros and cons of the procedure. This statement emphasizes the importance of informed consent, which requires that the patient receives information about the procedure, risks, benefits, and alternatives before providing their consent.

Choice C rationale:

Stating that verbal consent is acceptable unless the surgical procedure is an emergency is not accurate. Informed consent generally requires written documentation, except in true emergencies when obtaining written consent is not possible due to the patient's condition.

Choice D rationale:

The statement that a family member must witness the client's signature on the informed consent form is not a universal requirement for informed consent. While witnesses may be necessary in some cases, it is not a standard requirement for all surgical procedures. The focus should be on ensuring that the client understands the information provided before consenting.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is postpartum about the measles, mumps, and rubella (MMR) vaccine.Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client who is about to undergo surgery.Which of the following statements about informed consent should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease.The client becomes agitated and combative when the nurse approaches him.Which of the following actions should the nurse plan to take?

A nurse is contributing to the plan of care for a client who reports insomnia due to increased stress.Which of the following interventions is the nurse's priority?

A nurse is assisting with the plan of care for a client who is scheduled for hemodialysis via an arteriovenous fistula in the arm. Which of the following actions should the nurse recommend?

A nurse is assisting with the care of a client who is receiving a spinal epidural to treat a herniated disc.Which of the following findings should the nurse identify as an indicator of unrelieved pain?

A nurse is collecting data from a newborn who weighs 5,160 g (11 lb, 6 oz) and whose mother has diabetes mellitus.For which of the following data should the nurse monitor?

A nurse is preparing a client's body for a postmortem family viewing. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with the parents of an infant who has a Pavlik harness. Which of the following statements should the nurse include in the teaching?

A nurse is reinforcing teaching with the partner of a client who is receiving hospice care about music therapy for pain management.Which of the following statements by the partner indicates an understanding of the teaching?