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 D

Explanation

A. In adults insert catheter approximately 16 cm (6.5 inches); in older children, 8– 12 cm (3–5 inches); in infants and young children, 4–7.5 cm (1.5–3 inches). Rule of thumb is to insert catheter distance from tip of nose (or mouth) to angle of mandible.
B. Suction should not be applied while inserting the catheter, as it could cause trauma to the mucosa and increase discomfort. Suction should only be applied while withdrawing the catheter, and it should be done intermittently to avoid injury and reduce the risk of hypoxia.
C. Suctioning should not exceed 10-15 seconds at a time to prevent hypoxia and other complications. Prolonged suctioning can lead to oxygen depletion and potential respiratory distress in the client.
D. Waiting at least 1 minute between suctioning attempts allows the client to recover and helps maintain adequate oxygenation. This pause is essential to prevent hypoxia and to ensure the client has time to breathe normally before the next suctioning attempt.

A. Limit the client's social interactions. B. Encourage the client to be assertive. C. Assume responsibility for making the client's decisions. D. Maintain a verbal no-harm contract with the client.

Correct Answer is B

Explanation

A. Incorrect. Limiting the client's social interactions would not be helpful and might further exacerbate feelings of dependence.
B. Correct. Encouraging the client to be assertive is an important aspect of promoting independence and self-advocacy. Clients with dependent personality disorder may struggle with asserting themselves, and fostering assertiveness can improve their overall well-being.
C. Incorrect. Assuming responsibility for making the client's decisions would reinforce their dependence, which is not the goal of treatment.
D. Incorrect. Maintaining a verbal, no-harm contract is typically used for clients at risk of self-harm or harm to others and is not directly related to addressing the challenges of dependent personality disorder.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing nasopharyngeal suctioning for an adult client. Which of the following techniques should the nurse use?

Correct Answer is D

Explanation

A nurse is reinforcing discharge teaching with the caregiver of a client who has a dependent personality disorder. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is completing postmortem documentation for a client. Which of the following information should the nurse include in the documentation?

A nurse is assisting with postmortem care for a client who was a devout follower of Islam. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a new mother about facility security measures. Which of the following statements by the mother indicates an understanding of the teaching?

A nurse is contributing to an in-service for newly licensed nurses about situations requiring an Incident report. Which of the following examples should the nurse include?

A nurse is assisting with the planning of an in-service about updates in wound care for nursing staff. Which of the following sources should the nurse identify as providing the best evidence-based information?

A nurse is caring for a client who has end-stage kidney disease. The client has decided to stop dialysis treatment. Which of the following actions should the nurse take?

A nurse is assisting with discharge planning for a client who is prescribed home oxygen at 1 to 2 L/min. The nurse should ensure that the client has which of the following supplies upon discharge?

A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the following actions should the nurse take first?