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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Observing the client during and after meals is crucial for monitoring their eating behaviors, identifying any signs of bingeing or purging, and assessing their overall progress in managing their eating disorder. By closely observing the client, the nurse can provide immediate support and intervention if necessary and help prevent or address any potentially harmful behaviors. Instructing the client about effective coping strategies is valuable in helping them develop healthier ways to manage stress and emotions. However, this instruction can be more effective once the nurse has observed the client's behaviors and identified specific areas where coping strategies are needed.
Suggesting that the client assist with meal planning can be a helpful step in empowering them to take ownership of their eating habits and make healthier choices. However, before involving the client in meal planning, it is important to first assess their current eating behaviors and address any immediate concerns or risks.
Referring the client to a support group for individuals with eating disorders is a beneficial step in providing ongoing support and community. However, this referral can be made once the nurse has established a baseline understanding of the client's behaviors and needs.
Observing the client during and after meals is crucial for monitoring their eating behaviors, identifying any signs of bingeing or purging, and assessing their overall progress in managing their eating disorder. By closely observing the client, the nurse can provide immediate support and intervention if necessary and help prevent or address any potentially harmful behaviors. Instructing the client about effective coping strategies is valuable in helping them develop healthier ways to manage stress and emotions. However, this instruction can be more effective once the nurse has observed the client's behaviors and identified specific areas where coping strategies are needed.
Suggesting that the client assist with meal planning can be a helpful step in empowering them to take ownership of their eating habits and make healthier choices. However, before involving the client in meal planning, it is important to first assess their current eating behaviors and address any immediate concerns or risks.
Referring the client to a support group for individuals with eating disorders is a beneficial step in providing ongoing support and community. However, this referral can be made once the nurse has established a baseline understanding of the client's behaviors and needs.
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.
Weight loss is typically associated with inadequate calorie or nutrient intake, rather than fluid overload.
Weight loss is typically associated with inadequate calorie or nutrient intake, rather than fluid overload.
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