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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.

A.

Encourage prolonged dangling before ambulation.

B.

Irrigate indwelling catheter with 500 mL of fluid.

C.

Administer an enema.

D.

Assist the client with a sitz bath.

E.

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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Related Questions

Correct Answer is A

Explanation

Monitoring the infant's lymphocyte count is important in evaluating the immune function of the infant. HIV primarily affects the immune system, including lymphocytes. Monitoring the lymphocyte count helps assess the progression of the disease and the effectiveness of treatment.

Exchange transfusions are not typically used in the management of HIV. They are primarily performed in conditions like severe neonatal jaundice or blood disorders, but not for the treatment of HIV.

Granulocyte colony-stimulating factor (G-CSF) is a medication used to stimulate the production of white blood cells called granulocytes. While G-CSF can be used in certain situations, such as to counteract the side effects of certain chemotherapy drugs, it is not a standard treatment for HIV in infants.

Droplet precautions are typically implemented for infectious diseases that spread through respiratory droplets, such as influenza or respiratory syncytial virus (RSV). HIV does not spread through respiratory droplets, so initiating droplet precautions would not be necessary in the care of an infant with HIV.

Correct Answer is B

Explanation

This statement shows that the mother understands the importance of having matching identification bands for herself and her baby. Matching identification bands help ensure proper identification and prevent any mix-ups or unauthorized individuals from gaining access to the baby. It is a security measure commonly implemented in healthcare facilities to protect the well-being and safety of both the mother and the newborn.

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