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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Assisting the client to the bathroom at regular intervals helps prevent falls due to toileting needs.
B. Locking the wheels on the bed prevents unwanted movement and reduces the risk of falls when the client is in bed.
C. Raising all four side rails is considered a restraint, which can increase the risk of falls or injury if the client tries to climb over them. Restraints should be avoided unless absolutely necessary and prescribed by a healthcare provider. In most cases, raising two side rails is sufficient to prevent the client from accidentally rolling out of bed while allowing them to safely exit the bed.
D. Clearing the path from obstacles and furniture reduces the risk of falls by providing a safe and unobstructed route to the bathroom.
Correct Answer is C
Explanation
A. Incorrect. Security bands should not be removed or transferred to others. They help ensure the correct identification of both the mother and the baby.
B. Incorrect. Carrying the baby to the nursery might not be necessary, and newborns should be transported in a safe manner, often in a crib.
C. Correct. Both the mother and the baby should have matching identification bands to prevent mix-ups and ensure proper identification.
D. Incorrect. Newborns should generally remain in designated safe areas, like the mother's room or the nursery, to ensure their safety and security.
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