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.

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Correct Answer is B

Explanation

A. Patterned-paced breathing might help with pain management, but it's not specific to changing positions.
B. Correct. Splinting the incision with a pillow provides support and reduces strain when changing positions, minimizing discomfort.
C. Counterpressure to the back might be helpful during contractions, but it's not specific to postoperative pain with position changes.
D. While reducing position changes might be initially suggested, it's important for postoperative clients to move to prevent complications like deep vein thrombosis. Providing strategies to manage pain during position changes is more appropriate.

A. Potatoes B. Oranges C. Grapes D. Corn

Correct Answer is C

Explanation

A. Potatoes are generally considered safe for toddlers to consume, as they are usually cooked until they are soft and easy to chew.
B. Oranges can be a choking hazard if not cut into small, manageable pieces, but they are less likely to cause choking than some other foods.
C. Correct. Grapes are small and round, making them a significant choking hazard for toddlers.
They can easily become lodged in a toddler's airway.
D. Corn kernels can also be a choking hazard for toddlers, especially if they are not chewed thoroughly or if the toddler eats them directly off the cob.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

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 C

Explanation

A nurse is reviewing the medical records of five clients. For which of the following events should the nurse write an incident report? (Select all that apply.)

A nurse is reinforcing teaching with a client about reducing dietary caffeine intake. The nurse should remind the client that 240 mL (8 oz. of which of the following beverages contains the least amount of caffeine?

A nurse is assisting with the care of a client who is receiving a spinal epidural to treat a herniated disc. Which of the following findings should the nurse identify as an indicator of unrelieved pain?

A nurse in a long-term care facility is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA. Which of the following actions should the nurse take?

A nurse is collecting data from a client during a routine prenatal visit. The client is in their second trimester of pregnancy and reports feeling dizzy, has a racing heart, and becomes pale while lying on their back. Which of the following actions should the nurse take?

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 verifying informed consent for a client who is preoperative for a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent?

A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hr. PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this client care incident?