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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Pelvic rocking exercises can help relieve lower back pain during pregnancy. The client can perform this exercise by getting on their hands and knees, keeping their back straight, and gently rocking their pelvis back and forth. This helps to stretch and strengthen the muscles in the lower back and pelvis.
A. Sit in a hot tub for 30 min every evening: Hot tubs and hot baths are not recommended during pregnancy as they can raise the body temperature too high, which can be harmful to the developing fetus.
B. Raise chairs to keep knees lower than hips: This recommendation is more appropriate for promoting good posture and reducing strain on the back, but it may not specifically address lower back pain.
C. Use the arms to pick up heavy items: It is important to avoid heavy lifting during pregnancy as it can strain the back and increase the risk of injury. It is recommended to use proper lifting techniques, such as bending the knees and using the leg muscles rather than the back muscles, to lift objects.
Correct Answer is C
Explanation
For a client with a prepregnancy BMI of 30.5, the acceptable weight gain during pregnancy would be around 11 to 20 pounds (5 to 9 kilograms) according to the guidelines set by the Institute of Medicine (IOM).
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