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 B
Explanation
Disorientation is a common side effect of ECT and is typically temporary. It may include confusion and difficulty recalling recent events or personal information. This post-treatment disorientation is often referred to as the "postictal state" and usually resolves within a short period of time.
Sleep apnea, tonic-clonic seizures, and paresthesias are not expected findings following ECT and would require immediate attention and intervention if they were to occur. It is important for the nurse to closely monitor the client's vital signs, oxygen saturation levels, and neurological status after the procedure to ensure their safety and well-being.
Correct Answer is C
Explanation
explanation:
Adult day care facilities provide a safe and supervised environment for older adults during the day, while their family members or caregivers are at work or unable to be present. These facilities offer various activities, social interactions, and personal care services to support the needs of individuals with dementia and other conditions. Attending an adult day care facility canalso give the client an opportunity to engage with others and maintain cognitive and physical stimulation.
A- Hospice care is generally recommended for individuals with terminal illnesses who are nearing the end of life. It focuses on providing comfort and support to the patient and family during the end-of-life journey.
B- Long-term care facilities may be appropriate for some individuals with advanced dementia who require round-the-clock care and supervision. However, in this scenario, the client's adult child is present and working full time, suggesting that the family intends to provide care at home as much as possible.
D- Community senior centers may offer various activities and programs for older adults, but they may not provide the level of supervision and care required for an individual with early onset dementia during the day, especially if their family member is at work.
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