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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A- "My partner will use condoms with spermicides": Using condoms with spermicides can increase the effectiveness of contraception by combining a barrier method with a chemical method to kill sperm.

B.Using two condoms simultaneously (also known as "double bagging") is not recommended because the friction between them can increase the chance of them tearing.

C- "I will be able to remove my contraceptive sponge immediately after intercourse": The contraceptive sponge is a barrier method that is inserted into the vagina before intercourse. It should be left in place for at least 6 hours after intercourse to ensure effectiveness. Removing it immediately after intercourse would decrease its contraceptive effectiveness.

D- "My partner and I will use petroleum jelly with latex condoms": Petroleum jelly, along with other oil-based lubricants, should not be used with latex condoms. Oil-based substances can degrade latex, making the condom more prone to breakage. Water-based lubricants are recommended for use with latex condoms to ensure their integrity and effectiveness.

A. Apply a skin barrier protectant to the site. B. Apply water-soluble lubricant to the site. C. Tape the tube to the child's cheek. D. Attach an extension tube to the site's opening prior to use.

Correct Answer is A

Explanation

A- Apply a skin barrier protectant to the site: Using a skin barrier protectant helps shield the peristomal skin from irritation and breakdown caused by gastric contents and formula leakage.

B- Apply water-soluble lubricant to the site: Similarly, applying a water-soluble lubricant to the site is not a routine step in gastrostomy tube site care. Lubricants are typically used during the insertion of the tube or for intermittent tube feedings, but not for routine site care.

C- Tape the tube to the child's cheek: Taping the tube to the child's cheek is not necessary for routine site care. The tube should be secured using a dressing or device designed for gastrostomy tube stabilization, rather than taping it to the cheek.

D.Attaching an extension tube is related to administering feedings or medications rather than the maintenance and care of the gastrostomy site. Site care focuses on protecting the skin and ensuring cleanliness around the tube insertion area.

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 reinforcing teaching with a female client about contraception. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is providing site care for a child who has a gastrostomy enteral tube. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect?​​​​​​​

A community health nurse is developing a brochure about hypertension. Which of the following actions should the nurse take?

A nurse is collecting data from a client who is 2 days postpartum. The client tells the nurse she cannot afford to pay for baby formula. The nurse should refer the client to which of the following members of the interprofessional team?

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

A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take?

A nurse is contributing to the plan of care for a client who has leukemia and is experiencing chronic fatigue. Which of the following interventions should the nurse plan to include?

A nurse is reinforcing teaching with a client who is dependent on nicotine and wishes to discontinue smoking. The nurse should inform the client that which of the following is a manifestation of nicotine withdrawal?