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.

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Correct Answer is C

Explanation

A.This is incorrect because suction should not be applied during the insertion of the catheter. Suctioning should only be applied while withdrawing the catheter to avoid causing trauma to the mucosa.

B. Suctioning should generally be performed for no longer than 10 seconds at a time to minimize the risk of complications such as hypoxia.

C.This response is correct because waiting approximately 1 minute between suctioning attempts allows the client time to recover and reoxygenate. This interval helps prevent hypoxia and mucosal damage, which are important considerations during the suctioning process.

D.In adults insert catheter approximately 16 cm (6.5 inches); in older children, 8– 12 cm (3–5 inches); in infants and young children, 4–7.5 cm (1.5–3 inches). Rule of thumb is to insert catheter distance from tip of nose (or mouth) to angle of mandible.

A. Avoid breastfeeding for 3 days after receiving the vaccine. B. Your partner should also receive the MMR vaccine. C. If you are allergic to gluten you should not receive this vaccine. D. Avoid pregnancy for at least 28 days after receiving the vaccine.

Correct Answer is D

Explanation

Explanation:

Avoid pregnancy for at least 28 days after receiving the vaccine: This is a crucial instruction for women of childbearing age. The MMR vaccine is a live attenuated vaccine, and women should avoid becoming pregnant for at least 28 days after receiving it to reduce the theoretical risk to the developing fetus. Pregnant women should not receive the MMR vaccine, and women who receive the vaccine should avoid getting pregnant for at least 28 days afterward.

Incorrect:

A- Avoid breastfeeding for 3 days after receiving the vaccine: This statement is not accurate. Breastfeeding is not contraindicated after receiving the MMR vaccine. In fact, breastfeeding is safe and can be continued as usual.

B- Your partner should also receive the MMR vaccine: While it is essential for individuals to be vaccinated against measles, mumps, and rubella for their own protection and to contribute to herd immunity, it is not a specific instruction given to the postpartum client.

C- If you are allergic to gluten, you should not receive this vaccine: The MMR vaccine does not contain gluten, and a gluten allergy is not a contraindication for receiving the vaccine.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing nasopharyngeal suctioning for an adult client. Which of the following techniques should the nurse use?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who is postpartum about the measles, mumps, andrubella (MMR) vaccine. Which of the following instructions should the nurse include in theteaching?

Correct Answer is D

Explanation

A nurse is reinforcing dietary teaching with a client who has constipation about appropriate food choices. Which of the following food selections by the client demonstrates an understanding of the teaching?

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?

A nurse is verifying informed consent for a client who is preoperative for a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent?

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 an in-service for newly licensed nurses about situations requiring an incident report. Which of the following examples should the nurse include?

A nurse is caring for a client who has bulimia nervosa. Which of the following actions should the nurse take first?

A nurse is reinforcing teaching with the parents of an infant who has a Pavlik harness. Which of the following statements should the nurse include in the teaching?

A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures?