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
Levothyroxine is a medication used to treat hypothyroidism, and monitoring the TSH levels helps determine the effectiveness of the medication.
Blood urea nitrogen (BUN) is a test used to assess kidney function and is not specifically related to thyroid function or levothyroxine therapy.
Prothrombin time (PT) is a test used to evaluate the clotting ability of the blood and is not directly related to thyroid function or levothyroxine therapy.
Arterial blood gases (ABGs) are used to assess oxygen and carbon dioxide levels in the blood and evaluate acid-base balance. ABGs are not specifically related to thyroid function or levothyroxine therapy.
Correct Answer is D
Explanation
Explanation:
Avoid pregnancy for at least 28 days after receiving the vaccine: This is a crucial instruction for women of childbearing age. The MMR vaccine is a live attenuated vaccine, and women should avoid becoming pregnant for at least 28 days after receiving it to reduce the theoretical risk to the developing fetus. Pregnant women should not receive the MMR vaccine, and women who receive the vaccine should avoid getting pregnant for at least 28 days afterward.
Incorrect:
A- Avoid breastfeeding for 3 days after receiving the vaccine: This statement is not accurate. Breastfeeding is not contraindicated after receiving the MMR vaccine. In fact, breastfeeding is safe and can be continued as usual.
B- Your partner should also receive the MMR vaccine: While it is essential for individuals to be vaccinated against measles, mumps, and rubella for their own protection and to contribute to herd immunity, it is not a specific instruction given to the postpartum client.
C- If you are allergic to gluten, you should not receive this vaccine: The MMR vaccine does not contain gluten, and a gluten allergy is not a contraindication for receiving the vaccine.
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