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
Informed consent is a process where the healthcare provider explains the risks, benefits, and alternatives of a proposed procedure or treatment to the client. The client then demonstrates their understanding of this information and voluntarily agrees to undergo the procedure or treatment.
A. "I will have a large scar on my stomach after this procedure". This is incorrect for a vaginal hysterectomy, which does not involve an abdominal incision.
B. 'I am thankful I am done having children." This statement reflects an understanding of a key consequence of a hysterectomy, which is the removal of the uterus and the resulting inability to have children. This indicates that the client is aware of and accepts the major impact of the surgery on their reproductive capabilities.
C."I should expect my periods to resume in 1 month.": This is incorrect because the removal of the uterus means the client will no longer have menstrual periods.
D."I will no longer need a regular gynecological examination.": This is incorrect because regular gynecological examinations are still necessary to monitor overall reproductive health and screen for other conditions.
Correct Answer is ["A","C","D"]
Explanation
Correct:
A. Creating a stimulating environment helps engage the client and can reduce restlessness and agitation. This can include activities, social interactions, and sensory stimulation tailored to the individual's preferences.
C. Clients with Alzheimer's disease may become overwhelmed and have difficulty making decisions when presented with too many options. By limiting choices, caregivers can help reduce confusion and frustration for the client.
D. Clients with Alzheimer's disease may experience memory impairment and difficulty with orientation. Using written signs can help them navigate their surroundings and locate essential areas, such as the bathroom. Clear and simple signs can be helpful for maintaining independence and minimizing confusion.
incorrect:
B. Confrontation, which involves challenging or arguing with the client, can escalate agitation and distress. Instead, caregivers should use techniques such as redirection, validation, and providing a calm and supportive environment to manage challenging behaviors associated with Alzheimer's disease.
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