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.

Answer and Explanation

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

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Correct Answer is B

Explanation

Veracity refers to the principle of truthfulness and honesty in communication. By truthfully communicating about the adverse effects of the prescribed medications, the nurse is demonstrating veracity. This ethical principle emphasizes the importance of providing accurate information to the client to promote informed decision-making and autonomy.

Justice refers to fairness and equitable treatment, ensuring that individuals receive what they are due and that resources are distributed appropriately. While justice is an important ethical concept in healthcare, it is not directly applicable to the nurse's communication about adverse effects.

Autonomy refers to respecting the right of individuals to make their own decisions and choices regarding their healthcare. While truthfully communicating about adverse effects supports autonomy, autonomy itself is not the specific ethical concept being exhibited in this scenario. Beneficence refers to the ethical principle of acting in the best interest of the client and promoting their well-being. While providing accurate information about adverse effects can be seen as a form of beneficence, it does not directly address the nurse's truthful communication in this specific scenario.

A. "I should not feed my baby anything for 2 hours prior to an immunization." B. "My baby will receive three doses of the meningococcal immunization before kindergarten." C. “My baby will receive the rotavirus immunization orally." D. "I should expect my baby to have a high fever for 24 hours after an immunization.”

Correct Answer is C

Explanation

"My baby will receive the rotavirus immunization orally." - This statement is correct. The rotavirus vaccine is administered orally, typically as drops or as an oral suspension. It is important for the guardian to follow the specific instructions provided by the healthcare provider for the administration of the rotavirus vaccine.

"I should not feed my baby anything for 2 hours prior to an immunization." - This statement is incorrect. It is not necessary to withhold feeding prior to immunizations. In fact, it is generally recommended to feed the baby before the immunization to help provide comfort during the procedure.

"My baby will receive three doses of the meningococcal immunization before kindergarten." This statement is incorrect. The number of doses and the schedule for each immunization may vary. The guardian should consult with the healthcare provider or refer to the immunization schedule for the specific recommendations regarding the meningococcal immunization.

"I should expect my baby to have a high fever for 24 hours after an immunization." - This statement is not entirely accurate. While it is common for infants to experience mild side effects such as a low-grade fever after immunizations, a high fever is less common. The guardian should be aware of the potential side effects and contact the healthcare provider if they have concerns about their baby's reaction to the immunization.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has been admitted to the mental health unit. While reinforcing teaching about the client's prescribed medications, the nurse communicates truthfully about the adverse effects of the medications. Which of the following ethical concepts is the nurse exhibiting?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with the guardian of a 2-month-old infant about immunizations. Which of the following statements by a guardian indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse working in a mental health facility is caring for a client who is pacing back and forth in the day room while wringing their hands. Which of the following actions should the nurse take?

A nurse is reinforcing discharge teaching with a client who has stable angina pectoris. Which of the following statements by the client indicates an understanding of what to do when chest pain occurs?

A nurse is assisting with the plan of care for a 10-month-old infant who has HIV. Which of the following interventions should the nurse include in the plan?

A nurse is contributing to the plan of care for a client who is experiencing a herpes simplex outbreak. Which of the following interventions should the nurse recommend?

A nurse is collecting data from a client who has placenta previa. Which of the following findings should the nurse expect?

A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?

A nurse is collecting data from a client who is in renal failure. The nurse should identify that which of the following findings is a manifestation of hyperkalemia?

A nurse is assisting in developing a list of internet sites for clients to obtain valid health information. When evaluating internet resources, which of the following findings indicates the information likely contains credible medical information?