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:

Grapes are a choking hazard for toddlers due to their small size and round shape. Young children can easily choke on grapes if they are not cut into smaller pieces or grapes are not adequately supervised during consumption. Educating parents and caregivers about cutting grapes into smaller, more manageable pieces is crucial to prevent choking incidents.

Choice B rationale:

Oranges (choice B) are generally not considered a high choking hazard for toddlers. However, parents and caregivers should still exercise caution and cut oranges into small, manageable pieces to reduce the risk of choking.

Choice C rationale:

Potatoes (choice C) can be a choking hazard for toddlers if not prepared and served appropriately. It is essential to cut potatoes into small, soft pieces and ensure that toddlers are supervised during mealtime to prevent choking incidents.

Choice D rationale:

Corn (choice D) can also pose a choking hazard for toddlers, especially if served on the cob. To minimize the risk, parents and caregivers should cut corn into small, bite-sized pieces or remove it from the cob before serving to young children.

A. "I will cleanse my skin using an antibacterial soap.” B. "I will dry my skin by patting it with a towel.” C. "I will use an astringent on my face.” D. "I will limit my time in the tanning bed to 15 minutes.”

Correct Answer is B

Explanation

Choice A rationale:

Cleansing the skin with an antibacterial soap is not typically recommended for clients with systemic lupus erythematosus (SLE) unless there is a specific medical indication for antibacterial soap. Using mild, non-irritating, hypoallergenic soap is usually preferred to avoid skin irritation in individuals with SLE.

Choice B rationale:

This is the correct answer. Patting the skin dry with a towel instead of rubbing it helps to prevent excessive friction and irritation, which can be particularly important for individuals with SLE who may have sensitive skin. The client demonstrates an understanding of appropriate skin care by choosing this option.

Choice C rationale:

Using an astringent on the face is generally discouraged for individuals with SLE. Astringents can be harsh and may irritate the skin, which can exacerbate skin problems commonly associated with SLE. This statement indicates a misunderstanding of appropriate skin care.

Choice D rationale:

Limiting time in the tanning bed is advisable for anyone, as excessive exposure to UV radiation can increase the risk of skin damage and skin cancers. However, individuals with SLE are especially sensitive to UV radiation, and they should avoid tanning beds altogether. This statement indicates a lack of understanding of the specific needs of individuals with SLE regarding sun exposure.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A community health nurse is assisting with the development of a pamphlet regarding choking hazards for toddlers.Which of the following foods should the nurse include?

Correct Answer is A

Explanation

A nurse in a provider's office is reinforcing teaching about skin care with a client who has a new diagnosis of systemic lupus erythematosus.Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is discussing the plan of care of a client who is 4 hr postoperative and has a urostomy with an assistive personnel. Which of the following statements should the nurse include in the discussion?

A nurse is assisting in the care of an older adult client who was admitted from a long-term care facility. Exhibits Select the 3 findings that require immediate follow-up.

A nurse is reinforcing teaching with a female client about contraception. Which of the following statements by the client indicates an understanding of the teaching?

A nurse in a long-term care facility observes an assistive personnel who is incorrectly monitoring a client's blood glucose level. The nurse should report this observation to which of the following personnel first?

A nurse is collecting data from a newborn who weighs 5,160 g (11 lb, 6 oz) and whose mother has diabetes mellitus.For which of the following data should the nurse monitor?

A nurse is preparing to administer carbamazepine suspension 150 mg via NG tube every 6 hr. The amount available is 100 mg/5 mL. How many mL should the nurse administer with each dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is collecting data from a client who received oxytocin 10 units IM 30 min ago for excessive vaginal bleeding.Which of the following findings should the nurse expect?