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 C

Explanation

A. Slurred speech is not a common adverse effect of gentamicin.
B. Hypotension is not a common adverse effect of gentamicin.
C. Correct. Gentamicin is an aminoglycoside antibiotic known for its potential to cause hearing loss (ototoxicity..
D. Constipation is not a common adverse effect of gentamicin.

A. The client has state-sponsored health insurance. B. The client's next dressing change is scheduled in 4 hr. C. The client's vital signs are checked every 8 hr. D. The client has developed difficulty ambulating.

Correct Answer is D

Explanation

A. While the client's health insurance status is important for financial considerations, it might not be relevant to the interprofessional team meeting.
B. The timing of the client's dressing change and vital signs are specific care details that may not be essential for the interprofessional team.
D. Correct. The client's difficulty ambulating is a significant change in their condition that may impact care decisions and require input from the interprofessional team.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

A nurse is participating in an interprofessional team meeting for a client. Which of the following information about the client should the nurse include?

Correct Answer is D

Explanation

A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following information should the nurse include?

A nurse is reinforcing teaching about newborn care with a new guardian. Which of the following statements by the guardian indicates an understanding of the teaching?

A nurse in a mental health facility is caring for a client who expresses anxiety about exercising in the outdoor courtyard. The nurse promises to walk with the client in the courtyard each day. Which of the following ethical principles is the nurse demonstrating?

A nurse is assisting in providing postmortem care for a client who was a devout follower of Hinduism. Which of the following requests should the nurse anticipate from the client's family?

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 in a long-term care facility is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA. Which of the following actions should the nurse take?

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 reinforcing teaching with a client who is to have a plaster cast applied to his right arm. Which of the following information should the nurse include in the teaching?