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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Correct Answer is A

Explanation

A. Correct. Isosorbide dinitrate is a medication used to prevent angina. Headaches are a common side effect when starting the medication, but they often decrease over time as the body adjusts.
B. Incorrect. Swallowing the tablet whole will not necessarily minimize headaches associated with isosorbide dinitrate.
C. Incorrect. Taking the medication on an empty stomach is not typically necessary to prevent headaches.
D. Incorrect. Discontinuing the medication without consulting a healthcare provider is not recommended, as abrupt discontinuation could lead to worsening of symptoms.

A. Increase dietary potassium. B. Withhold the medication if the pulse rate is less than 60/min. C. Decrease daily fluid intake. D. Rise slowly from a sitting position to a standing position.

Correct Answer is D

Explanation

A. Incorrect. While monitoring dietary potassium might be relevant for some clients on certain medications, it is not the primary action for addressing syncope related to enalapril.
B. Incorrect. Withholding the medication based solely on pulse rate is not an appropriate action.
The nurse should provide guidance on appropriate management.
C. Incorrect. Decreasing daily fluid intake is not likely to address the syncope related to enalapril.
D. Correct. Enalapril is an ACE inhibitor, and syncope can be a side effect due to changes in blood pressure. Advising the client to rise slowly from a sitting position can help prevent sudden drops in blood pressure and decrease the risk of syncope.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports he has headaches after taking chewable isosorbide dinitrate. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

A nurse at an outpatient clinic receives a call from a client who reports experiencing syncope after starting a new prescription for enalapril. Which of the following instructions should the nurse give the client?

Correct Answer is D

Explanation

A nurse is assisting in the care of a client who presents to the emergency department. Exhibits A nurse is reviewing the client's medical record, which of the following findings indicates the need for further evaluation? Select all that apply.

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 is reviewing laboratory findings for three clients. Which of the following laboratory results should the nurse expect for a client who has pancreatitis?

A nurse is caring for a client in bed and begins experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

A nurse working in a mental health facility is caring for a client who is pacing back and forth in the day room while wringing their hands. Which of the following actions should the nurse take?

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?

A nurse is providing site care for a child who has a gastrostomy enteral tube. Which of the following actions should the nurse take?

A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV Infusion. Which of the following manifestations should the nurse identify as an adverse effect of the treatment?