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 D

Explanation

A) "I will wash my baby’s head using a moist towelette": Using a moist towelette to wash a newborn’s head is not the best approach. Newborns should be bathed gently with warm water and mild soap, especially for sensitive areas like the scalp. A moist towelette could irritate the baby’s delicate skin or lead to unnecessary chemicals on the skin.

B) "I will give my baby a bath every day": Giving a newborn a bath every day is not typically necessary. Bathing a newborn 2-3 times per week is usually sufficient to keep the baby clean without drying out the skin. Daily baths can be too harsh on a newborn’s skin, especially in the first few weeks.

C) "I will bathe my baby under a faucet of running water": Bathing a newborn under running water can be dangerous, as it may be difficult to control the temperature of the water or the baby could be at risk of slipping. It is safer to use a basin of warm water and a soft washcloth to gently bathe the baby.

D) "I will wash my baby's face with a warm, wet washcloth without soap": This is the correct and safe approach to washing a newborn’s face. Newborns have very sensitive skin, and it’s best to wash the face with just warm water and a soft washcloth to avoid irritation. Using soap on the face may dry out or irritate their delicate skin.

A. "I should decrease my salt intake to 2 grams per day." B. ‘’I can have two glasses of wine with dinner." C. "I should exercise for 5 minutes two times per week." D. "I will set my blood pressure goal at 130 over 84."

Correct Answer is A

Explanation

A) "I should decrease my salt intake to 2 grams per day.":
This statement is correct. For clients with hypertension, a reduced salt intake is essential in managing blood pressure. The general recommendation is to limit sodium intake to less than 2,300 milligrams per day (about 2.3 grams), with an ideal target of 1,500 milligrams per day for individuals with hypertension or those at risk. Reducing salt intake helps lower blood pressure and prevent further complications.

B) "I can have two glasses of wine with dinner.":
This statement is incorrect. While moderate alcohol consumption may not be prohibited, it is important for individuals with hypertension to limit alcohol intake. The American Heart Association recommends no more than one drink per day for women. Two glasses of wine may exceed this limit, which could contribute to an increase in blood pressure.

C) "I should exercise for 5 minutes two times per week.":
This statement is incorrect. Exercise is an important component of managing hypertension, but 5 minutes of exercise twice a week is not sufficient. The general recommendation is for adults to engage in at least 150 minutes of moderate-intensity aerobic exercise or 75 minutes of vigorous-intensity exercise per week, spread throughout the week. More frequent and longer exercise sessions are necessary to improve cardiovascular health and manage blood pressure.

D) "I will set my blood pressure goal at 130 over 84.":
This statement is incorrect. The goal for blood pressure in individuals with mild hypertension is generally lower than 130/80 mm Hg, according to current guidelines. A blood pressure of 130/84 is still considered elevated. The target should be to maintain a blood pressure below 130/80 mm Hg to reduce the risk of cardiovascular complications.

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

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Explanation

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Correct Answer is A

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