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 C
Explanation
Choice A rationale:
"Fidelity involves ensuring that we do no harm to the client." - This statement is not an accurate description of fidelity. Fidelity, in ethical terms, primarily refers to keeping promises and being loyal to clients, rather than preventing harm.
Choice B rationale:
"Fidelity involves making sure clients are able to make their own health care decisions." - While this statement relates to ethical principles, it is more closely associated with the principle of autonomy rather than fidelity. Fidelity is about keeping promises and being trustworthy.
Choice C rationale:
"Fidelity involves keeping promises made to clients." - This is the correct answer. Fidelity is the ethical principle that involves keeping commitments, promises, and agreements made to clients. It emphasizes the importance of honesty, trustworthiness, and integrity in the nurse-patient relationship.
Choice D rationale:
"Fidelity involves treating every client with the same level of respect." - While respecting clients is essential in nursing practice, this statement does not directly address the concept of fidelity. Fidelity is more about keeping promises and being loyal to individual clients rather than a uniform approach to all clients.
Correct Answer is C
Explanation
Choice A rationale:
Offering toileting opportunities every 1 to 2 hours is a reasonable intervention in a bladder training program, but it should not be the first action. Before establishing a toileting schedule, the nurse should assess the client's current voiding patterns to determine the most appropriate schedule based on the client's needs.
Choice B rationale:
Assisting the client with relaxation techniques can be beneficial in managing urinary incontinence or frequency, but it should not be the first action. Understanding the client's voiding pattern and any factors contributing to their urinary issues is essential before implementing relaxation techniques.
Choice C rationale:
Determining the client's pattern for voiding is the first step in developing a tailored bladder training program. This assessment helps identify the client's specific needs and enables the nurse to create a personalized plan that addresses their issues effectively.
Choice D rationale:
Discouraging intake of carbonated beverages is a valid intervention in managing urinary incontinence or frequency, but it should not be the first action. It's important to assess the client's individual habits and patterns before making dietary recommendations.
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