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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Correct Answer is C

Explanation

Nausea and vomiting are common side effects of doxycycline, an antibiotic commonly used to treat chlamydial infections. Taking the medication with food or a snack can help alleviate these side effects. The recommendation to take the medication with crackers provides a light source of carbohydrates that can help settle the stomach and reduce nausea.

It is generally not recommended to take doxycycline with calcium-rich foods or beverages, as they can interfere with the absorption of the medication. Calcium can form complexes with doxycycline, reducing its effectiveness. Therefore, it is best to avoid calcium-rich foods and beverages, including calcium-fortified orange juice, when taking doxycycline.

Similar to calcium-rich foods, antacids can also interfere with the absorption of doxycycline. Antacids contain aluminum, magnesium, or calcium, which can bind to doxycycline and reduce its effectiveness. Therefore, it is generally recommended to avoid taking doxycycline with antacids.

While it is important to remain upright for a short period after taking some medications to prevent reflux or aspiration, this recommendation may not specifically address the client's nausea and vomiting. Taking the medication with food, such as crackers, may be more effective in alleviating the symptoms.

A. Instruct the client to take a brisk walk B. Position the client on their left side C. Check the client's temperature D. Provide the client with a glass of orange juice

Correct Answer is B

Explanation

The client's symptoms of feeling dizzy, having a racing heart, and becoming pale while lying on their back are consistent with supine hypotension syndrome, also known as vena cava syndrome. This occurs when the weight of the uterus compresses the inferior vena cava, reducing blood flow and causing symptoms.

To address this issue, the nurse should Position the client on their left side. Lying on the left side helps relieve the pressure on the inferior vena cava and improves blood flow. This can alleviate the symptoms and prevent further complications.

Instructing the client to take a brisk walk is not appropriate in this situation, as it may exacerbate the symptoms by increasing heart rate and potentially causing further dizziness or fainting. Checking the client's temperature is not necessary in relation to these symptoms, as they are not indicative of a fever or infection.

Providing the client with a glass of orange juice may be helpful in some situations, such as if the client is experiencing hypoglycemia. However, in this case, the symptoms are likely due to supine hypotension syndrome, and repositioning the client is the priority intervention.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a chlamydial infection and a new prescription for doxycycline. The client reports nausea and vomiting after starting the medication. Which of the following recommendations should the nurse make?

Correct Answer is C

Explanation

A nurse is collecting data from a client during a routine prenatal visit. The client is in their second trimester of pregnancy and reports feeling dizzy, has a racing heart, and becomes pale while lying on their back. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?

A nurse is preparing to perform a wet-to-dry dressing change for a client who has an infected abdominal wound. Which of the following techniques should the nurse use when performing this dressing change?

A nurse is discussing the plan of care of a client who is 4 hr postoperative and has a urostomy with assistive personnel. Which of the following statements should the nurse include in the discussion?

A nurse is caring for a client who is cyanotic and has a respiratory rate of 8/min with shallow respirations. Which of the following is the priority action by the nurse?

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?

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A nurse is caring for a client who has end-stage kidney disease. The client has decided to stop dialysis treatment. Which of the following actions should the nurse take?