Select the 2 actions the nurse should prepare to take for the client.

Encourage prolonged dangling before ambulation.

Administer an enema.

Encourage oral fluid intake.

Irrigate indwelling catheter with 500 mL of fluid.

Assist the client with a sitz bath.

Answer and Explanation

Correct Answer : C,E

A. Encourage prolonged dangling before ambulation.
Prolonged dangling is not necessary for this client, who is already ambulating independently. Extended dangling may increase the risk of orthostatic hypotension without providing significant benefits.

B. Administer an enema.
An enema is not the first-line intervention for postoperative constipation. The client has had a bowel movement, albeit small and painful, so increasing fluids and noninvasive measures like a sitz bath should be attempted first.

C. Encourage oral fluid intake.
Adequate hydration helps soften stool and prevent constipation, a common postoperative concern. The client’s fluid intake should be increased to support bowel function and improve urinary output.

D. Irrigate indwelling catheter with 500 mL of fluid.
The client has pink urine but is maintaining an adequate output of 100 mL/hr. Routine catheter irrigation is unnecessary unless there is evidence of obstruction, such as decreased urine flow or clot formation.

E. Assist the client with a sitz bath.
A sitz bath can provide comfort by promoting relaxation of perineal muscles, reducing pain during bowel movements, and improving circulation to the surgical site, which may aid healing.

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Correct Answer is C

Explanation

A) "Put small cushion under the newborn's head for support.":
This statement is incorrect. Placing a small cushion or any additional padding under a newborn’s head in a car seat is not recommended. Extra padding can interfere with the proper fit of the harness and could pose a safety risk in the event of a crash. The car seat should be used as designed, without extra padding that could affect the infant's positioning.

B) "Position the car seat at a 90° angle.":
This statement is incorrect. The car seat should be positioned at a 45-degree angle, not 90 degrees. A 45-degree angle helps prevent the infant’s head from falling forward, which can obstruct the airway and cause breathing difficulties. Positioning the seat at the correct angle ensures that the baby’s head and neck are properly supported.

C) "Place the shoulder harnesses at the level of the infant's shoulders.":
This statement is correct. For optimal safety, the shoulder harness straps should be at or just below the infant's shoulders when they are in a rear-facing car seat. This positioning helps to keep the baby secure and ensures the harness fits properly in the event of an accident. The harness should be snug and positioned correctly to provide the best protection.

D) "Keep the airbag on if the car seat is in the front seat.":
This statement is incorrect. It is recommended that infants and young children always be placed in a rear-facing car seat in the back seat of the vehicle, as this is the safest position. Airbags can be dangerous to infants if the car seat is in the front seat. If the car seat must be placed in the front seat (which is not recommended), the airbag should be turned off to prevent injury in the event of a crash.

A. Beefy, red tongue B. Paroxysmal cough C. Peeling of the hands and feet D. Fever

Correct Answer is D

Explanation

A) Beefy, red tongue: The beefy, red tongue is typically associated with scarlet fever, a bacterial infection caused by group A Streptococcus. This condition can lead to a red, "strawberry" tongue, often accompanied by a rash. While measles can involve a variety of symptoms, including a red rash, conjunctivitis, and cough, the beefy red tongue is not characteristic of measles. In measles, the more notable symptoms are a high fever, cough, runny nose, and the development of Koplik spots inside the mouth.

B) Paroxysmal cough: Paroxysmal cough, which is a sudden, severe, and uncontrollable cough often followed by a "whooping" sound, is more characteristic of pertussis (whooping cough). While a cough is indeed present with measles, it is generally not paroxysmal. In measles, the cough is more persistent and associated with other typical symptoms such as fever and a characteristic rash. The coughing in measles may also be dry and harsh but does not tend to occur in violent, paroxysmal episodes like those seen in pertussis.

C) Peeling of the hands and feet: Peeling of the skin, particularly of the hands and feet, is more commonly observed in conditions such as scarlet fever, Kawasaki disease, or after a viral infection like hand-foot-and-mouth disease. It is not a classic finding of measles. In measles, the skin rash usually starts as maculopapular spots on the face and spreads down the body. While some skin sloughing can occur after the rash resolves, especially in severe cases, it is not the characteristic sign of measles, and it is not typically seen on the hands and feet.

D) Fever: Fever is one of the earliest and most prominent symptoms of measles. It typically appears about 2-4 days before the characteristic measles rash. The fever in measles can be quite high, often exceeding 104°F (40°C), and is associated with other symptoms such as cough, conjunctivitis, and photophobia. The fever usually persists for several days, and it is one of the critical signs that lead to the diagnosis of measles, particularly when combined with the characteristic rash and other respiratory symptoms.

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Select the 2 actions the nurse should prepare to take for the client.

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Correct Answer is D

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