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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
The statement "Avoid breastfeeding for 3 days after receiving the vaccine" is not accurate. Breastfeeding can continue after the MMR vaccination without any adverse effects on the infant. There is no need to interrupt breastfeeding.
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.
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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