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 A
Explanation
Correct. Pelvic rocking exercises can help alleviate lower back pain during pregnancy by promoting movement and flexibility in the pelvic area.
Picking up heavy items with the arms might not directly address lower back pain during pregnancy.
Sitting in a hot tub for extended periods is not recommended during pregnancy due to the risk of overheating.
Raising chairs to keep knees lower than hips is a general ergonomic recommendation, but it might not directly address lower back pain.
Correct Answer is D
Explanation
A. Incorrect. Assisting the client with relaxation techniques can be helpful in managing bladder training, but determining the client's voiding pattern is the first step in designing an effective program.
B. Incorrect. Discouraging the intake of carbonated beverages might be part of the bladder training plan, but the first step is to assess the client's current voiding pattern.
C. Incorrect. Offering toileting opportunities every 1 to 2 hours is part of the bladder training program, but determining the client's voiding pattern is the initial action.
D. Correct. The nurse should first determine the client's pattern for voiding, including the frequency of voiding and any patterns of urgency or incontinence. This information is essential to tailor the bladder training program to the client's individual needs.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.