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

The correct answer is: a. Displacement.

Choice A Reason: Displacement is a defense mechanism where a person redirects a negative emotion from its original source to a less threatening recipient. In the context of bipolar disorder, a client may displace anger or frustration about their condition or treatment onto the nurse, who is not the source of these feelings. This redirection can occur because the client might feel powerless or uncomfortable expressing these emotions towards their healthcare provider, who is the authority figure prescribing medication changes.

Choice B Reason: Splitting is often associated with borderline personality disorder rather than bipolar disorder. It involves viewing things in extremes—either all good or all bad—with no middle ground. While individuals with bipolar disorder can exhibit black-and-white thinking, especially during mood episodes, the behavior described does not indicate splitting, as it does not involve idealizing or devaluing the nurse or provider.

Choice C Reason: Sublimation is a mature defense mechanism where socially unacceptable impulses or idealizations are unconsciously transformed into socially acceptable actions or behavior, often resulting in a long-term conversion of the initial impulse. For example, a person with aggressive tendencies might take up a sport that channels aggression in a socially acceptable way. The scenario provided does not suggest that the client is channeling their frustrations into a constructive activity.

Choice D Reason: Conversion involves the transfer of mental stress into physical symptoms. This defense mechanism is characteristic of conversion disorder, where psychological stress manifests as neurological symptoms like blindness, paralysis, or other sensory or motor symptoms without a medical cause. The client yelling at the nurse does not reflect a conversion of emotional distress into physical symptoms.

A. Request an x-ray of the preschooler's neck. B. Initiate droplet precautions. C. Administer fluconazole to the preschooler. D. Monitor the preschooler's urine for protein.

Correct Answer is B

Explanation

Choice A rationale:

"Request an x-ray of the preschooler's neck." - This action is not indicated for a preschooler with manifestations of respiratory syncytial virus (RSV) RSV primarily affects the respiratory system, and an x-ray of the neck would not be relevant for this condition.

Choice B rationale:

"Initiate droplet precautions." - This is the correct answer. RSV is highly contagious and primarily spreads through respiratory droplets. Initiating droplet precautions, such as wearing a mask and practicing proper hand hygiene, is essential to prevent the transmission of the virus to others in the healthcare setting.

Choice C rationale:

"Administer fluconazole to the preschooler." - Fluconazole is an antifungal medication and would not be appropriate for treating RSV, which is a viral respiratory infection. Antifungal medications are used to treat fungal infections, not viral ones.

Choice D rationale:

"Monitor the preschooler's urine for protein." - Monitoring urine for protein is not relevant to the care of a preschooler with RSV. This action is more suitable for conditions that may affect the kidneys or urinary system but not RSV, which primarily affects the respiratory system.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has bipolar disorder. The client yells at the nurse whenever medication changes are prescribed by the client's provider. The nurse should identify that the client is using which of the following defense mechanisms?

Correct Answer is A

Explanation

A nurse is assisting with the care of a preschooler who has manifestations of respiratory syncytial virus. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse in an urgent care clinic is caring for a client who reports recently using methylenedioxy-methamphetamine. Which of the following findings should the nurse expect?

A nurse is caring for an older adult client who wears hearing aids with detachable ear molds.Which of the following actions should the nurse take when caring for the hearing aids?

A nurse is caring for a client who speaks a different language than the nurse.Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a client who is taking allopurinol about the risk for developing Stevens-Johnson syndrome.For which of the following manifestations should the nurse instruct the client to monitor and report?

A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis.Which of the following interventions should the nurse recommend to include in the plan?

A nurse is contributing to the plan of care for a client who has leukemia and is experiencing chronic fatigue.Which of the following interventions should the nurse plan to include?

A nurse is collecting data from a client who has placenta previa.Which of the following findings should the nurse expect?

A nurse is reinforcing teaching with a client who has an open leg wound and is experiencing difficulty healing.The nurse should encourage the client to increase which of the following nutrients in his diet?