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:

Placing a pulse oximeter on the client's finger to assess oxygen saturation is important, but in this scenario, establishing a patent airway takes priority. The client's cyanosis and shallow respirations indicate a severe respiratory distress, and the nurse should first ensure the client's ability to breathe before assessing oxygen levels.

Choice B rationale:

Establishing a patent airway is the priority action because the client's shallow respirations and cyanosis indicate a compromised airway and inadequate oxygenation. Ensuring a clear airway is crucial for the client's survival.

Choice C rationale:

Checking the client's pulse rate is an important assessment but should not take precedence over addressing the airway and breathing issues. The client's respiratory distress is a more immediate concern.

Choice D rationale:

Administering oxygen is an appropriate intervention, but it should not be done before ensuring a patent airway. The nurse must prioritize actions to address the most critical issue first.

A. "Tilt your head forward while inhaling.” B. "Exhale immediately after inhaling.” C. "Close your mouth around the mouthpiece.” D. "Take three quick breaths while depressing the canister.”

Correct Answer is C

Explanation

Choice A rationale:

Tilt your head forward while inhaling is not an appropriate instruction for using an albuterol metered-dose inhaler (MDI) In fact, it is recommended to keep the head in a neutral position while using an MDI to ensure proper delivery of the medication to the lungs. Tilted head positions can lead to ineffective inhalation and may result in the medication being deposited in the mouth or throat rather than reaching the lungs. Therefore, choice A is not the correct answer.

Choice B rationale:

Exhale immediately after inhaling is not an accurate instruction for using an albuterol MDI. The correct sequence is to inhale slowly and deeply through the mouth while pressing down on the canister to release the medication, hold the breath for a few seconds (usually 10 seconds), and then exhale slowly. Exhaling immediately after inhaling would not allow the medication to reach the lower airways effectively. Therefore, choice B is not the correct answer.

Choice C rationale:

"Close your mouth around the mouthpiece" is an essential instruction for using an albuterol MDI correctly. It ensures that the medication

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is cyanotic and has a respiratory rate of 8/min with shallow respirations.Which of the following is the priority action by the nurse?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client who is about to start using an albuterol metered-dose inhaler.Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

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 in an acute mental-health facility is caring for an adolescent who is exhibiting destructive behavior. Which of the following actions should the nurse take after applying physical restraints to the client?

A nurse is reinforcing teaching with a client who is about to undergo electroconvulsive therapy.The nurse should explain to the client that which of the following adverse reactions can occur following the procedure?

A nurse is caring for a client who recently gave birth to her first child.The newborn is crying, and the client states, "I can't seem to do anything right.What should I do?" Which of the following responses should the nurse make?

A nurse is assisting in the care of a client who is to undergo an amniotomy.Which of the following is the priority nursing action following this procedure?

A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hr PRN for pain.The nurse inadvertently administers 2 tablets to the client.In which of the following locations should the nurse document this client care incident?

A nurse is assisting with the plan of care for a client who has botulism poisoning.Which of the following interventions should the nurse include in the plan?

A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following information should the nurse include?