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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Free Nursing Study Resources

Correct Answer is A

Explanation

a.This requires intervention because creases in the stockings can create pressure points that may lead to skin irritation or impaired circulation. The stockings should be applied smoothly and evenly to ensure proper compression and to avoid skin complications.

b.This is not necessary and can actually be incorrect. Antiembolic stockings should be applied with the correct side facing the client's skin. Turning them inside out could alter their effectiveness in providing the required compression.

c.This is appropriate. Applying antiembolic stockings before the client gets out of bed is recommended because it helps to promote venous return and prevent blood clots, especially if the client is immobile or has limited mobility.

d.This is appropriate. Asking the client to point their toes helps to ensure that the stockings can be applied correctly and fit well, reducing the risk of creating pressure points or causing discomfort.

A. Fidelity involves keeping promises made to clients. B. Fidelity involves making sure clients are able to make their own health care decisions. C. Fidelity involves ensuring that we do no harm to the client. D. Fidelity involves treating every client with the same level of respect.

Correct Answer is A

Explanation

A. Fidelity involves keeping promises made to clients

Fidelity is an ethical principle that pertains to the nurse's duty to be faithful, loyal, and keep promises made to clients. It involves acting in a trustworthy and reliable manner, maintaining commitments, and upholding the client's rights and autonomy.

Option B is incorrect because it refers to autonomy, which is another ethical principle that involves respecting the client's right to make their own health care decisions.

Option C is incorrect because it refers to nonmaleficence, which is the principle of ensuring that we do no harm to the client and avoiding actions that may cause harm or have a negative impact on the client's well-being.

Option D is incorrect because it refers to justice, which involves treating every client with fairness, equality, and respect, but it does not specifically address the concept of fidelity.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is supervising an assistive personnel (AP) who is applying antiembolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse?

Correct Answer is A

Explanation

A nurse is reviewing information about ethical client care with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of fidelity?

Correct Answer is A

Explanation

Oxygen at 1 to 2 L/min. The nurse should ensure that the client has which of the following supplies upon discharge?

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 reviewing the medical record for a child who is scheduled to receive a varicella immunization. Which of the following findings in the client's record should the nurse recognize as a contraindication?

A nurse is assisting with the care of a preschooler who has manifestations of respiratory syncytial virus. Which of the following actions should the nurse take?

A nurse is collecting data from a client who has a long leg cast on his left leg. Which of the following findings is the priority?

A nurse is assisting with planning an in-service for staff members about active shooter protocols. Which of the following information should the nurse recommend?

A nurse in an assisted-living facility is reinforcing teaching with staff members about preparing for an external chemical disaster. Which of the following instructions should the nurse include?

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?