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 D
Explanation
The correct answer is choiced. “I try not to look at the scales on my body.”
Choice A rationale:Limiting time spent in sunlight is generally a good practice for individuals with psoriasis, as excessive sun exposure can trigger flare-ups or worsen symptoms.
Choice B rationale:Removing old medication before applying a new dose is a proper practice to ensure the effectiveness of the treatment and prevent skin irritation.
Choice C rationale:Avoiding fabric softener is advisable for individuals with psoriasis, as fabric softeners can contain chemicals that may irritate sensitive skin.
Choice D rationale:This statement indicates a potential psychological impact of psoriasis on the client. It suggests that the client might be experiencing distress or avoidance behavior due to the appearance of their skin, which should be reported to the provider for further assessment and support.
Correct Answer is ["B"]
Explanation
The correct answer is choice b. Reduced fat in the stools.
Choice A rationale:
Decreased sodium excretion is not a therapeutic effect of pancrelipase. Pancrelipase is an enzyme replacement therapy that helps in the digestion of fats, proteins, and carbohydrates, but it does not affect sodium excretion.
Choice B rationale:
Reduced fat in the stools is the correct answer. Pancrelipase helps in the digestion of fats, which reduces the amount of fat excreted in the stools. This is particularly important for patients with cystic fibrosis, who often have pancreatic insufficiency leading to malabsorption of fats.
Choice C rationale:
Improved respiratory function is not a direct therapeutic effect of pancrelipase. While better nutrition and absorption can indirectly support overall health, including respiratory function, pancrelipase specifically targets digestive enzyme insufficiency.
Choice D rationale:
Improved absorption of vitamins B and C is not the primary therapeutic effect of pancrelipase. Pancrelipase aids in the absorption of fat-soluble vitamins (A, D, E, and K) rather than water-soluble vitamins like B and C.
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