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

Phenytoin is known to cause gingival hyperplasia, which is characterized by swollen and enlarged gums. This side effect is more common in long-term use and may require dental care and regular oral hygiene practices.

Phenytoin is known to be associated with an increased risk of birth defects in babies born to women taking the medication during pregnancy. It is important for women of childbearing age to discuss the risks and benefits of phenytoin with their healthcare provider and use effective contraception to avoid pregnancy while taking the medication.

Phenytoin can affect liver function, so regular monitoring of liver enzymes and blood levels of the medication is necessary. The frequency of blood work may vary depending on the individual's specific situation, so it is important to follow the healthcare provider's instructions.

It is not advisable to skip a dose of phenytoin without consulting a healthcare provider. Abruptly stopping or missing doses of antiepileptic medications can lead to breakthrough seizures or other complications. Any changes in the medication regimen should be discussed with the healthcare provider.

A. "The client's partner visited earlier today for 2 hours." B. "The client received the prescribed antibiotic every 8 hours." C. "The client reports pain is reduced when he is positioned on his side." D. "The client's mother died 4 years ago from breast cancer."

Correct Answer is ["B","C"]

Explanation

The client received the prescribed antibiotic every 8 hours: This is important information as it relates to the client's medication administration and treatment plan. It allows the incoming nurse to be aware of the medication schedule and ensure continuity of care.

The client reports pain is reduced when positioned on his side: This is significant information as it informs the incoming nurse about the client's preferred position for pain management. It helps guide the nurse in providing comfort measures and appropriate positioning for the client.

The client's mother died 4 years ago from breast cancer: This information may not be considered vital for the change-of-shift report unless it directly impacts the client's current condition or ongoing care.

While it's important to document visitors and support persons, this information may not be considered crucial for the change-of-shift report unless it directly impacts the client's care or well-being.

In summary, the nurse should include information that is pertinent to the client's immediate care needs and current condition. This includes medication administration, pain management preferences, changes in condition, or any relevant information that may impact the client's care plan.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a female client who is taking phenytoin. Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is providing a change-of-shift report for a client. Which of the following information should the nurse include in the report?

Correct Answer is ["B","C"]

Explanation

A nurse is supervising an assistive personnel (AP) who is applying antiembolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse?

A nurse is reinforcing teaching with a client who is scheduled for an intravenous pyelogram. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hr PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this client care incident?

A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. The nurse should place the client in which of the following positions?

A nurse is collecting data from a client who is 1 day postoperative following a transurethral resection of the prostate. Which of the following findings should the nurse report to the provider?

A nurse is assisting in the care of a client who presents to the emergency department. Exhibits A nurse is reviewing the client's medical record. Which of the following findings indicates the need for further evaluation? Select all that apply.

A nurse is assisting in developing a list of internet sites for clients to obtain valid health information. When evaluating internet resources, which of the following findings indicates the information likely contains credible medical information?