Nurses' Notes Postoperative Day 3 0900:

The client reports pain at the surgical incision site as 5 on a scale of 0 to 10. The client reports bladder fullness. Perineal dressing intact with minimal serosanguinous drainage. The client transferred out of bed to a chair independently. Extremities cool and dry with 2+ peripheral pulses.

1300:

The client reports abdominal cramping and small, hard, painful bowel movements after lunch. Ambulating independently in the hallway. Reports pain as 8 on a scale of 0 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.

Irrigate the indwelling catheter with 500 mL of fluid.

Assist the client with a seat bath.

Encourage oral fluid intake.

Administer an enema.

Encourage prolonged dangling before ambulation.

Answer and Explanation

Correct Answer : B,C

A. Not indicated and could lead to complications.

B.   The client reports abdominal cramping and a small, hard, painful bowel movement. A sit bath can help provide relief and comfort to the perineal area, which can be beneficial after experiencing bowel discomfort.
C.   The client reports pain and has had a small, hard, painful bowel movement. Encouraging oral fluid intake helps prevent dehydration and can soften the stool, making it easier to pass and reducing the risk of constipation.
D.   Not necessary or appropriate without further assessment.

E. Not necessary and may not provide any additional benefit in this context.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A. Correct. Measuring abdominal girth daily is important to monitor for changes in ascites and fluid retention.
B. Restricting sodium intake is important for clients with ascites to manage fluid retention, but a specific limit of 3 g per day is not universally applicable.
C. Protein intake should not be significantly restricted for clients with ascites; protein is essential for maintaining adequate serum albumin levels.
D. Positioning the client supine with legs elevated might be uncomfortable and not directly related to managing ascites.

A. "You should lay down for 1 hour following a meal." B. "You should eat three large meals and two snacks per day." C. "You should only drink 2 cups of coffee per day." D. "You should elevate the head of the bed while sleeping."

Correct Answer is D

Explanation

A. Incorrect. Laying down immediately after a meal can worsen GERD symptoms. Remaining upright for at least 23 hours after eating is recommended.
B. Incorrect. Eating large meals can exacerbate GERD symptoms. Smaller, more frequent meals are advised.
C. Incorrect. While coffee can trigger GERD symptoms in some, specifying a particular number of cups may not be appropriate. Avoiding triggers and monitoring symptoms is the general advice.
D. Correct. Elevating the head of the bed while sleeping helps prevent stomach acid from flowing back into the esophagus, reducing nighttime GERD symptoms.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

A nurse is reinforcing teaching about disease management with a client who has GERD. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

A nurse is reinforcing teaching for a client who has a new ascending colostomy. Which of the following comments by the client indicates an understanding of the teaching?

A nurse is reinforcing teaching with a client who is postoperative following a laparoscopic cholecystectomy. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is assisting with preparing a client who is to have a central venous catheter inserted for the administration of total parenteral nutrition (TPN. Which of the following actions should the nurse take?

A nurse is assisting in the care of a client who is at 34 weeks of gestation and is experiencing lower back pain. Which of the following recommendations should the nurse make?

A nurse is completing postmortem documentation for a client. Which of the following information should the nurse include in the documentation?

A nurse is collecting data from a client who has thrombocytopenia. The nurse should identify which of the following findings increases the client's risk for injury.

A nurse is contributing to the plan of care for a client who is experiencing a herpes simplex outbreak. Which of the following interventions should the nurse recommend?

A nurse is implementing a bladder training program for a client who had a stroke. Which of the following interventions should the nurse take first?