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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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Incorrect. Over-the-counter topical ointments may worsen herpes simplex outbreaks.
B. Correct. Cleaning skin eruptions with povidone-iodine helps prevent secondary infection.
C. Incorrect. Antiviral medications, not antibiotics, are used to treat herpes simplex outbreaks.
D. Incorrect. Disposable thermometers are not directly related to herpes simplex outbreak management.

A. Write the information at an 8th-grade reading level. B. Explain medical terminology using basic, one-syllable words. C. Present information from complex to simple. D. Use a 12-point font size.

Correct Answer is A

Explanation

A. Correct. To ensure the information is accessible to a wide audience, it should be written at an 8th-grade reading level, which is suitable for the general population.
B. Using basic, one-syllable words is a good approach, but the reading level should also be considered.
C. Presenting information from complex to simple might be helpful, but starting with simpler concepts is more effective for understanding.
D. While font size is important for readability, the reading level of the content is more critical for comprehension.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who is experiencing a herpes simplex outbreak. Which of the following interventions should the nurse recommend?

Correct Answer is B

Explanation

A community health nurse is developing a brochure about hypertension. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?

A nurse is caring for a client who has schizophrenia and is taking an antipsychotic medication. Which of the following screening tools should the nurse use to identify tardive dyskinesia?

A nurse is reinforcing discharge teaching with a client who has a prescription for antibiotic therapy. The client reports experiencing diarrhea when taking antibiotics. Which of the following foods should the nurse recommend to lessen the occurrence of diarrhea?

A nurse is assisting with the care of a client. Exhibits Complete the following sentence by using the list of options. After notifying the provider, the nurse should and then

A nurse in a provider's office is caring for a group of clients who have communicable diseases. Which of the following infections should the nurse report to the state health department?

A nurse is reinforcing teaching with a client who has a new prescription for an epinephrine autoinjector PRN. The nurse should reinforce with the client that the medication can help treat which of the following manifestations?

A nurse is collecting data from a 4-month-old infant at a well-child visit. For which of the following findings should the nurse notify the provider?

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?