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 A

Explanation

Choice A rationale:

The appropriate response by the nurse in this situation is to consider the client's request and check with the charge nurse to see if it's possible to adjust the smoke breaks. This response demonstrates a willingness to listen to the client's request and explore the possibility of accommodating their needs within the unit's policies and routines. It does not immediately grant the request but shows respect for the client's concerns and attempts to find a compromise.

Choice B rationale:

Asking the client why they feel extra smoke breaks should be allowed is not the best response. It may come across as confrontational and defensive, which can escalate the situation. Clients with antisocial personality disorder may have difficulty adhering to rules, so it's essential to approach their requests with a collaborative and problem-solving attitude.

Choice C rationale:

Offering an extra smoke break in exchange for participation in group therapy is not an appropriate response. It can be seen as manipulating the client or using rewards to control their behavior. It's essential to maintain clear boundaries and not use rewards or punishments as a means of managing clients with personality disorders.

Choice D rationale:

Telling the client the smoking times on the unit are after each meal is not an appropriate response either. It doesn't address the client's request and simply restates the unit's policy. It's important to engage in a more therapeutic and client-centered approach when responding to requests from individuals with personality disorders.

A. Advocacy. B. Good manners. C. Customer service. D. Kindness.

Correct Answer is A

Explanation

Choice A rationale:

The nurse is demonstrating advocacy by contacting the provider to return and speak with the client when the client expresses a lack of understanding about their diagnosis. Advocacy involves promoting the client's best interests, ensuring they receive appropriate information and care, and facilitating communication between the client and the healthcare team to address their concerns and needs.

Choice B rationale:

Good manners, while important in nursing practice, do not capture the essence of the nurse's action in this scenario. The nurse's primary role is to advocate for the client's understanding and communication with the healthcare provider.

Choice C rationale:

Customer service is not the primary focus in this situation. While providing excellent customer service is important in healthcare, the nurse's primary responsibility is to ensure the client's understanding of their diagnosis and address any questions or concerns they may have.

Choice D rationale:

Kindness is a positive quality in nursing practice, but it does not fully encompass the nurse's role in this scenario. The nurse's primary responsibility is to advocate for the client's understanding and facilitate effective communication with the provider to address the client's concerns and questions.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has antisocial personality disorder who requests to smoke outside of scheduled smoke breaks.Which of the following is an appropriate response by the nurse?

Correct Answer is A

Explanation

A nurse is caring for a client who states, "My doctor was just here, but I still do not understand my diagnosis." The nurse contacts the provider to return to speak with the client.Which of the following principles is the nurse demonstrating?

Correct Answer is A

Explanation

The nurse is continuing to assist with the care of the client. Exhibits Select words from the choices below to fill in each blank in the following sentence. The complications that the client is at greatest risk for developing are dropdown and dropdown complications.

A nurse is assisting with the care of a client who has pneumonia. Exhibits For each potential nursing action, click to specify if the potential action is. anticipated or contraindicated for the client.

A nurse is completing postmortem documentation for a client. Which of the following information should the nurse include in the documentation?

A nurse is assisting with the discharge of an older adult client who has early onset dementia and lives with their adult child who works full time.Which of the following resources should the nurse recommend to the family to assist with the client's care?

A nurse is collecting data for a client who is receiving enteral tube feedings.The nurse should identify that which of the following findings is a manifestation of fluid overload?

A nurse is collecting data on a client who has a heart rate of 44/min.Which of the following findings should the nurse expect?

A nurse is providing care to a client who is immunocompromised. Which of the following should the nurse identify as a possible source of infection?

A nurse is administering pancrelipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment?