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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Fluid overload refers to an excess volume of fluid in the body, which can occur as a result of various factors, including excessive fluid intake or inadequate fluid removal. Crackles heard in the lungs, also known as rales, can indicate fluid accumulation in the lungs, a condition known as pulmonary edema. It is a common manifestation of fluid overload and can be detected through auscultation of the lungs.

Weight loss is typically associated with inadequate calorie or nutrient intake, rather than fluid overload.

A. Locks the wheels on the client's bed B. Clears furniture from the path leading to the bathroom C. Assists the client to the bathroom every 2 hr D. Raises all four side-rails on the client's bed

Correct Answer is D

Explanation

The nurse should intervene when the AP raises all four side-rails on the client's bed. While it is important to ensure the client's safety and minimize the risk of falls, raising all four side-rails can be considered a restraint and may not be the best practice for fall prevention. The use of physical restraints, including all four side-rails, can lead to adverse outcomes such as entrapment, increased agitation, and decreased mobility.

Locking the wheels on the client's bed: This is an appropriate action to prevent the bed from rolling and ensures stability.

Clearing furniture from the path leading to the bathroom: This is a good practice as it creates a clear and safe path for the client to walk without obstacles.

Assisting the client to the bathroom every 2 hours: This is a proactive measure to prevent falls by ensuring regular toileting and minimizing the need for the client to get up and move independently.

It's important to promote mobility and independence for the client while ensuring their safety.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data for a client who is receiving enteral tube feedings. The nurse should identify that which of the following findings is a manifestation of fluid overload?

Correct Answer is C

Explanation

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?

Correct Answer is D

Explanation

A nurse is completing postmortem documentation for a client. Which of the following information should the nurse include in the documentation?

A nurse is collecting data from a 4-month-old infant at a well-child visit. For which of the following findings should the nurse notify the provider?

A nurse is providing care to a client who is immunocompromised. Which of the following should the nurse identify as a possible source of infection?

A nurse is assisting with staff education about hand hygiene. Which of the following instructions should the nurse include in the teaching?

A nurse in an acute care facility is reviewing medication administration protocol with another nurse. Which of the following information should the nurse include in the review?

A nurse is reviewing laboratory findings for three clients. Which of the following laboratory results should the nurse expect for a client who has cirrhosis?

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

A nurse is reinforcing teaching with new parents about car seat safety. Which of the following instructions should the nurse include?