Read the information below.
- Client reports pain at surgical incision site as 5 on a scale of 0 to 10.
- Client reports bladder fullness. Perineal dressing intact with minimal serosanguinous drainage.
- Client transferring out of bed to chair independently.
- Extremities cool and dry with 2+ peripheral pulses.
- Client reports abdominal cramping and small, hard, painful bowel movement after lunch.
- Ambulating independently in hallway.
- Reports pain as 8 on a scale of 0 to 10, Urinary catheter intact with 100 mL/hr of pink urine.
Encourage prolonged dangling before ambulation.
Irrigate indwelling catheter with 500 mL of fluid.
Administer an enema.
Assist the client with a sitz bath.
Encourage oral fluid intake.
The Correct Answer is E
Adequate fluid intake helps to soften the stool, prevent constipation, and ease bowel movements. It can also help with bladder function and prevent urinary tract infections. This intervention is particularly relevant given the client's complaint of abdominal cramping and a small, hard, painful bowel movement.
The other options are not appropriate based on the information provided:
- "Encourage prolonged dangling before ambulation" is not necessary or relevant in this case. The client is already transferring out of bed to a chair independently and ambulating independently in the hallway, indicating sufficient mobility.
- "Irrigate indwelling catheter with 500 mL of fluid" is not indicated based on the provided information. The urinary catheter is intact, and the client is producing an appropriate amount of urine. There is no indication of urinary retention or need for irrigation.
- "Administer an enema" is not necessary at this point. The client has reported a small, hard, painful bowel movement, which indicates constipation. However, conservative measures such as encouraging oral fluid intake and possibly adding dietary fiber should be tried first before considering an enema.
- "Assist the client with a sitz bath" is not directly related to the client's current symptoms. A sitz bath is typically used for perineal hygiene, pain relief, or healing after certain surgical procedures, but it does not address the reported abdominal cramping or constipation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
An incident report is a tool used to document any unexpected or adverse event that occurs in the healthcare setting. It is important to report incidents to ensure proper investigation, analysis, and implementation of measures to prevent future occurrences.
In this example, the incident involves an error with an electronic IV pump resulting in the delivery of an incorrect amount of fluid, which can have serious implications for the client's safety and well-being.
The other examples listed may require further actions but may not necessarily require an incident report:
- A nurse discovers that a client's family member has administered a PCA dose: While it is concerning that a client's family member administered a patient-controlled analgesia (PCA) dose, it is more appropriate to address this situation through immediate intervention, education, and communication with the healthcare provider. An incident report may not be necessary unless there are further complications or system issues related to this incident.
- A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm: While the observation of improper restraint removal raises concerns about proper restraint protocol, it is more appropriate to address this situation through immediate intervention and communication with the involved nurse and healthcare provider. Depending on the severity of the situation, an incident report may or may not be warranted, but it is not the primary action in this case.
- A nurse observes a client vomiting after receiving an oral pain medication: While it is important to assess and address the client's condition and any adverse reactions, such as vomiting after receiving medication, it may not necessarily require an incident report. The nurse should assess the client, notify the healthcare provider, and document the incident appropriately in the client's medical record.
Correct Answer is D
Explanation
The APN, also known as a nurse practitioner or clinical nurse specialist, has advanced knowledge and expertise in pharmacology and medication management. They are trained to assess medication interactions, evaluate potential risks, and provide guidance to ensure safe and effective medication use.
The other members of the interdisciplinary team listed are not specifically trained to address medication interactions:
- Social worker: Social workers focus on addressing psychosocial aspects of care, such as emotional support, counseling, and resource coordination. While they may provide valuable assistance in various areas of the client's care, they typically do not have specialized knowledge in medication interactions.
- Patient care technician: Patient care technicians, also known as nursing assistants or certified nursing assistants, provide direct patient care under the supervision of nurses. They do not typically have the training or authority to address medication interactions.
- Psychologist: Psychologists specialize in the assessment, diagnosis, and treatment of mental and emotional health concerns. While they may be involved in the client's overall care, including medication management for mental health conditions, their expertise lies primarily in psychological assessment and therapy rather than medication interactions.
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