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 ["A","B","D"]

Explanation

The nurse should take the following actions when receiving a telephone prescription from a client's provider:

Ask the provider to spell out the name of the medication: This is important to ensure accurate transcription of the medication name. Spelling out the name helps prevent errors due to similar-sounding medications or confusion with abbreviations.
Request that the provider confirm the read-back of the prescription: This step ensures that the nurse and the provider are on the same page and that the prescription has been accurately transcribed. It allows for verification and correction if any discrepancies are identified.
Record the date and time of the telephone prescription: Documenting the date and time of the telephone prescription is essential for tracking and reference purposes. It helps establish a clear timeline of events and ensures proper documentation of the medication order.

It is not necessary to withhold the medication until the provider signs the prescription, as telephone prescriptions are typically followed up with a written prescription or electronic verification.

Instructing another nurse to record the prescription in the medical record may not be necessary, as the nurse who received the telephone prescription is responsible for accurately documenting the order in the medical record. However, if necessary, the nurse can delegate the task of documentation to another qualified staff member under their supervision, ensuring accuracy and completeness.

A. Colostrum provides many important antibodies that the newborn lacks. B. Colostrum contains iron, which is important for a newborn's brain development. C. Colostrum provides vitamin K. which is an essential nutrient for newborns. D. Colostrum contains a natural diuretic that stimulates the newborn to void.

Correct Answer is A

Explanation

Colostrum provides many important antibodies that the newborn lacks.

Colostrum is the thick, yellowish fluid produced by the breasts during the early days after giving birth. It is rich in antibodies, immune factors, and other beneficial components that provide important protection and support for the newborn's health. Colostrum is often referred to as "liquid gold" due to its valuable properties. Antibodies present in colostrum help to strengthen the newborn's immune system and provide protection against various infections and diseases.

These antibodies are especially important during the first few days of life when the newborn's own immune system is still developing.

Option B is incorrect because colostrum does not contain a significant amount of iron. Iron is generally obtained from other sources, such as breast milk or iron-fortified formula, to support the newborn's brain development.

Option C is incorrect because although colostrum contains various essential nutrients, it does not provide a significant amount of vitamin K. Vitamin K is typically given to newborns as a separate supplement to prevent vitamin K deficiency bleeding.

Option D is incorrect because colostrum does not act as a diuretic. Its primary role is to provide the newborn with essential nutrients, antibodies, and immune factors to support their overall health and development.

In summary, colostrum is important for the newborn because it provides valuable antibodies that the newborn lacks, helping to strengthen their immune system and protect against infections and diseases.

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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 receiving a telephone prescription from a client's provider. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

A nurse is reinforcing teaching about colostrum with a new mother who is breastfeeding. The mother asks. Why is colostrum so important for my baby? Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is caring for a client who has been admitted to the mental health unit. While reinforcing teaching about the client's prescribed medications, the nurse communicates truthfully about the adverse effects of the medications. Which of the following ethical concepts is the nurse exhibiting?

A nurse is helping to place a client into the prone position. The nurse should use a small pillow to relieve pressure from which of the following areas of the client's body?

A nurse at a long-term care facility is reviewing the plan of care for a client who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to an assistive personnel?

A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following actions should the nurse take to promote progression toward independence and mobility for the client?

A nurse is reinforcing teaching with a client who is dependent on nicotine and wishes to discontinue smoking. The nurse should inform the client that which of the following is a manifestation of nicotine withdrawal?

A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?

A nurse is collecting data from a client who is 2 days postpartum. The client tells the nurse she cannot afford to pay for baby formula. The nurse should refer the client to which of the following members of the interprofessional team?