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.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A.Having a health care proxy does not mean that the individual relinquishes their right to make their own decisions. A health care proxy is designated to make decisions on behalf of the individual when they are unable to do so, but the individual retains the right to make decisions if they are capable.

B.Having a health care proxy does not eliminate the need for a living will. A living will outline the individual's specific wishes regarding medical treatments and end-of-life care, while a health care proxy designates a person to make decisions on their behalf. Both documents serve different purposes and can work together to ensure the individual's wishes are respected.

C.A health care proxy designee is typically empowered to make medical decisions on your behalf, including signing consent forms if necessary. This is one of the primary roles of a health care proxy – to act in your best interests when you are unable to make decisions yourself, including signing forms for procedures or treatments.

D.The individual has the choice to name any person as their health care proxy designee, regardless of their relationship. It is important to choose someone who understands the individual's wishes and can make decisions in their best interest. The decision of whom to name as the health care proxy designee is personal and should be based on trust and understanding.

A. Do not include your child when making decisions about treatment. B. Ensure that your child does not receive the influenza vaccine annually. C. Have your child wear a medical identification wristband. D. Provide homeschooling for your child.

Correct Answer is C

Explanation

Wearing a medical identification wristband is important for children with chronic conditions such as cystic fibrosis. It helps alert others, including healthcare providers, about the child's condition in case of emergencies. The wristband can provide vital information about the child's diagnosis, treatment needs, and emergency contacts, ensuring appropriate care and timely interventions.

The other options mentioned are not appropriate or necessary for the care of a child with cystic fibrosis:

A- It is important to involve the child to an age-appropriate extent in decision-making about their treatment. Encouraging the child to participate in their own care and treatment decisions can promote their independence and self-management skills.

B- The influenza vaccine is generally recommended for children with cystic fibrosis, as they are at increased risk of respiratory infections. The vaccine helps protect against influenza and its potential complications. Therefore, the nurse should emphasize the importance of annual influenza vaccination for the child.

D- Homeschooling may not be necessary solely based on the diagnosis of cystic fibrosis. The decision regarding the child's education should be made based on their individual needs, abilities, and preferences, in consultation with the child's healthcare team and educational professionals.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about advance directives and a health care proxy. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with the guardians of a 6-year-old child who has cystic fibrosis. Which of the following information should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who reports he has headaches after taking chewable isosorbide dinitrate. Which of the following statements should the nurse make?

A nurse is supervising an assistive personnel (AP) who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene?

A nurse is assisting with postmortem care for a client who was a devout follower of Islam. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a client who has hypothyroidism and a new prescription for levothyroxine. The nurse should instruct the client to notify the provider of which of the following manifestations of thyrotoxicosis?

A nurse is assisting with the care of a client. Laboratory Results 1100: Abdominal ultrasound: mass present in small intestine proximal to ileocecal valve. Size of mass is 6 cm x 7 cm (2.4 in x 2.8 in). Select the 4 responsibilities the nurse has in relation to the client's advance directives.

A nurse is reinforcing teaching with a client who has a new prescription for epinephrine auto-injector PRN. The nurse should reinforce with the client that the medication can help treat which of the following manifestations?

A nurse is reinforcing teaching with a client who has GERD and a prescription for pantoprazole. Which of the following statements indicates an understanding of the teaching?

A nurse is caring for a client who has HIV and is neutropenic. Which of the following findings should the nurse identify as increasing the risk for the client to develop an infection?