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

Encourage prolonged dangling before ambulation.

Irrigate the 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 D

D. Assist the client with a sitz bath: A sitz bath can relieve perineal discomfort and promote relaxation of the pelvic floor muscles, which may help ease bowel movements. This is appropriate given the client's report of abdominal cramping and painful bowel movements.

E. Encourage oral fluid intake: The client had a total fluid intake of 1800 mL and urine output of 1400 mL over 12 hours. Encouraging adequate fluid intake is essential to maintain hydration, promote urine flow, and help prevent constipation, which the client is experiencing.

Incorrect Options:

A. Encourage prolonged dangling before ambulation: Prolonged dangling before ambulation is unnecessary in this case. The client is ambulating independently and does not exhibit signs of orthostatic hypotension that would require prolonged dangling.

B. Irrigate the indwelling catheter with 500 mL of fluid: There is no indication of a blocked catheter or need for irrigation. The pink urine suggests post-surgical changes but does not require immediate catheter irrigation.

C. Administer an enema: Although the client reports abdominal cramping and painful bowel movements, an enema is not the first-line intervention. Increasing fluid intake and using non-invasive measures like a sitz bath are preferable initial steps.

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Correct Answer is C

Explanation

Assessing the client's suicidal intent and the presence of a specific plan for self-harm is crucial in determining the level of immediate risk and the need for intervention. This question directly addresses the client's current state and potential danger.

While all the questions are important in assessing the client's situation, determining the presence of a plan for self-harm takes precedence as it helps evaluate the level of imminent danger and the need for immediate intervention.

The other questions are also important but can be addressed after ensuring the client's safety and appropriate intervention based on the information gathered regarding the plan for self-harm. These questions can provide additional information to further assess the client's support system, history, and current stressors, which can contribute to understanding the context and potential risk factors for the client.

Remember, if the client expresses an immediate plan and intent for self-harm, it is essential to take appropriate steps to ensure their safety, such as involving the appropriate mental health professionals, implementing a safety plan, and providing constant supervision as needed.

A. I'll take him back to the nursery, so you can get some rest. B. Let me show you how to swaddle and cuddle him, then you try. C. If I turn him on his side, maybe he'll go back to sleep. D. Babies need to cry soon after they are born to develop their lungs.

Correct Answer is B

Explanation

Let me show you how to swaddle and cuddle him, then you try.

The appropriate response for the nurse in this situation is to provide support and education to the new mother. Option B, "Let me show you how to swaddle and cuddle him, then you try," demonstrates a helpful and empowering approach.

I'll take him back to the nursery, so you can get some rest in (option A) is incorrect. This response dismisses the mother's concerns and suggests removing the baby from her care without addressing her need for guidance and support. It is important to encourage and assist the mother in learning how to care for her newborn rather than taking over the responsibility.

If I turn him on his side, maybe he'll go back to sleep in (option C) is incorrect. This response suggests a specific action without addressing the underlying concerns of the mother. It is important to provide guidance and reassurance rather than suggesting potential solutions without understanding the cause of the baby's crying.

Babies need to cry soon after they are born to develop their lungs in (option D) is incorrect. This response is not relevant to the mother's concerns and does not address her feelings of inadequacy. It is important to provide support and guidance in caring for the newborn rather than providing unrelated information.

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

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is expressing suicidal ideations. Which of the following questions is the nurse's priority?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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