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

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Correct Answer is A

Explanation

Placenta previa is a condition where the placenta partially or completely covers the cervix, leading to vaginal bleeding. The bleeding is typically painless and bright red in color. This is an important finding that should be assessed and monitored closely.

A rigid abdomen is not a characteristic finding of placenta previa. It could be a sign of another condition such as placental abruption or uterine rupture, which are separate complications. Fetal movement is not directly related to placenta previa. It is a normal finding and can vary depending on the gestational age and individual fetal patterns.

Placenta previa is not typically associated with persistent uterine contractions. However, it is important to monitor for any signs of preterm labor or other complications that could cause uterine contractions.

A. "You should take the medication on an empty stomach to prevent a headache." B. The headaches should decrease as you get used to the medication." C. "Swallow the tablet whole to minimize your headaches." D. "You can discontinue the medication until the headache goes away!"

Correct Answer is B

Explanation

Headaches are a common side effect of isosorbide dinitrate, especially when initially starting the medication. However, they often improve as the body adjusts to the medication. It is important to reassure the client that the headaches should decrease over time. If the headaches persist or worsen, the client should inform their healthcare provider for further evaluation and possible adjustment of the medication regimen.

The statement about taking the medication on an empty stomach is not relevant to preventing headaches associated with isosorbide dinitrate.

The statement about swallowing the tablet whole does not address the issue of headaches. Chewable isosorbide dinitrate is designed to be chewed or dissolved in the mouth, and swallowing it whole may not provide the intended therapeutic effect.

Discontinuing the medication until the headache goes away is not recommended without consulting the healthcare provider. Abruptly stopping or changing the dose of isosorbide dinitrate can have serious consequences and should only be done under medical supervision.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

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?

Correct Answer is B

Explanation

A nurse begins to bathe a newly admitted client who reports that they have not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following?

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?

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?

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 assisting with a group therapy session and notes a client who remains silent. Which of the following actions should the nurse take?

A nurse is collecting data from a client who reports feeling stress. Which of the following should the nurse identify as an external stressor?

A nurse is contributing to the plan of care for a client who is pregnant and reports having trouble sleeping. Which of the following instructions should the nurse include in the plan of care?

A nurse is caring for a client who has a new diagnosis of diabetes mellitus and is refusing to learn how to self-administer insulin. Which of the following responses should the nurse make?