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 D
Explanation
A.This belief is more common in preschool-age children who may not fully understand the permanence of death. School-age children generally have a better grasp of the concept of death being final.
B.Regression can occur in children of any age dealing with significant stress or trauma, but it is more typically seen in younger children. Older children might exhibit other forms of stress responses.
C.While alienation can happen, it is not the most typical response for a school-age child. They are more likely to seek support from peers or blame themselves through magical thinking, as they are still developing their understanding of complex emotional and social dynamics.
D.This choice reflects the magical thinking common in school-age children, where they might believe that their actions or thoughts can influence events. This can lead to feelings of guilt and responsibility for their sibling's illness or death.
Correct Answer is A
Explanation
A. Correct. Insomnia, or difficulty falling asleep or staying asleep, is a common manifestation of nicotine withdrawal.
B. Diarrhea is not a typical manifestation of nicotine withdrawal.
C. Weight gain, not weight loss, is more commonly associated with nicotine withdrawal.
D. Diaphoresis (excessive sweating. can be associated with nicotine withdrawal, but insomnia is a more direct withdrawal symptom.
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