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 B

Explanation

A. "I will take two 325 milligram aspirin tablets at the same time.": While aspirin is often recommended for heart attack prevention, taking two 325 mg tablets at the same time is not the standard recommendation for managing stable angina. The client should focus on using nitroglycerin as prescribed and seeking immediate medical attention if symptoms persist.

B. "I will stop what I am doing and lie down.": When chest pain occurs, the client should stop all activity and rest, preferably lying down. Resting can help reduce the heart's workload and alleviate the pain associated with stable angina.

C. "I will call the provider after taking one dose of nitroglycerin.": The correct action is to take one dose of nitroglycerin and wait five minutes. If the pain is not relieved, the client should take another dose and wait another five minutes. If the pain persists after three doses, the client should seek emergency medical help immediately rather than waiting to call the provider.

D. "I will hold my breath and bear down.": Holding the breath and bearing down (the Valsalva maneuver) is not recommended for relieving chest pain. This action can actually decrease venous return to the heart and increase strain on the heart, potentially worsening the situation.

A. Recurring urinary tract infections B. A recent move to a new city C. Lack of nutritional knowledge D. Report of feeling depressed

Correct Answer is B

Explanation

A. Incorrect. Recurring urinary tract infections are related to health and hygiene and are not typically considered external stressors.
B. Correct. A recent move to a new city is an external stressor because it is an environmental change that can lead to feelings of stress and adjustment.
C. Incorrect. Lack of nutritional knowledge is an internal stressor related to the client's knowledge and awareness, not an external factor.
D. Incorrect. Feeling depressed is an internal emotional state and is not an external stressor.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing discharge teaching with a client who has stable angina pectoris. Which of the following statements by the client indicates an understanding of what to do when chest pain occurs?

Correct Answer is B

Explanation

A nurse is collecting data from a client who reports feeling stress. Which of the following should the nurse identify as an external stressor?

Correct Answer is B

Explanation

A nurse is caring for a client who has paranoid schizophrenia and believes that they are being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make?

A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?

A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures?

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

A nurse is administering pancrelipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment?

A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?

A home health nurse is conducting a home inspection for a client who is at risk for falls. Which of the following instructions should the nurse provide for the client?

A nurse begins to bathe a newly admitted client who reports that they have not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following?