On the second postoperative day, a client who had a colon resection is starting to eat and ambulate with assistance. Although the client has a prescription for an oral analgesic, they request that the PCA containing morphine be continued for one more day due to fear of pain. Which intervention is most important for the nurse to implement?

Measure urinary output to ensure renal functioning.

Administer the oral analgesic medication an hour before discontinuing the PCA pump.

Monitor for a depressed respiratory rate.

Teach about the need to progress to a high-fiber diet.

Answer and Explanation

The Correct Answer is B

Choice A reason: Measuring urinary output is important for monitoring renal function, especially when using medications like morphine, but it is not the most critical intervention in this context.

Choice B reason: Administering the oral analgesic before discontinuing the PCA allows for the medication to take effect, preventing breakthrough pain and addressing the client's fear of pain.

Choice C reason: Monitoring for a depressed respiratory rate is crucial when a patient is on morphine, but the priority is to manage pain effectively as the client transitions to oral analgesics.

Choice D reason: Education on dietary needs is important for long-term recovery, but immediate pain management is a higher priority in the postoperative period.

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Correct Answer is B

Explanation

Choice A reason: Washing hands for a total of 20 seconds is recommended by the CDC as part of proper hand hygiene to prevent the spread of germs.

Choice B reason: Turning the water off using bare hands after washing can re-contaminate the hands. The CDC recommends using a paper towel to turn off the tap to avoid re-contamination.

Choice C reason: Keeping hands below elbows when rinsing is the correct procedure to prevent water from running down the arms onto the cleaned hands.

Choice D reason: Lathering using a circular movement is a recommended technique to ensure all surfaces of the hands are cleaned thoroughly.

A. Discuss that partners without similar symptoms may not be infected. B. Instruct the client on the importance of notifying sexual partners. C. Notify that persons with STIs are reported to local health departments. D. Provide counseling that most contraceptives protect against infection.

Correct Answer is B

Explanation

Choice A reason: Discussing symptomless partners may give false reassurance, as herpes can be transmitted even when symptoms are not present.

Choice B reason: Notifying sexual partners is crucial for public health and the prevention of further transmission of STIs.

Choice C reason: While it's true that STIs are reported, this does not provide the client with actionable advice for their situation.

Choice D reason: Most contraceptives do not protect against STIs like genital herpes, which is spread by skin-to-skin contact.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes an unlicensed assistive personnel (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

Correct Answer is B

Explanation

The nurse is caring for a client with the sexually transmitted infection (STI) genital herpes. The client reports having had prior sexually transmitted infections. Which response should the nurse provide?

Correct Answer is B

Explanation

A nurse is caring for a client with binge eating disorder. Which goal should the nurse establish first with the client?

A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. Which action should the nurse take first?

Patient Data Exhibits The nurse reviews the assessment findings along with the physician orders. Which immediate interventions would the nurse initiate? Select all that apply.

An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?

Patient Data Exhibits The nurse reviews new data. Which 5 nursing interventions are indicated for this client?

A client with cirrhosis of the liver reports a 5 lb (2.3 kg) weight gain within the last week during a physical assessment. Which assessment finding correlates with the client's report?