The practical nurse (PN) is assisting with preparation of a client for fecal diversion surgery. While inserting an indwelling urinary catheter, the client asks if the surgical opening will be visible. Which action should the PN implement?
Ask the client if he finished the bowel sterilization prescription.
Review the client's expectations of elimination after surgery.
Verify that the client had nothing by mouth (NPO) for the past 24 hours.
Determine if this is the first indwelling catheter the client has had.
The Correct Answer is B
A. Asking about the bowel sterilization prescription doesn't address the client's concern regarding the visibility of the surgical opening.
B. Reviewing the client's expectations after surgery could address the client's query about the visibility of the surgical opening and offer information regarding elimination.
C. Verifying the NPO status is important for surgery preparation but doesn’t directly address the client's specific concern.
D. Determining if this is the first indwelling catheter doesn’t directly address the client's immediate concern regarding the surgical opening.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Limiting sugar and caffeine intake can positively impact sleep and anxiety levels.
B. Drinking red wine at bedtime might initially induce sleep but could disrupt sleep patterns and worsen anxiety.
C. Reinforcing the reality of his financial situation might increase anxiety rather than diminish it.
D. Encouraging daily rituals might help establish a routine but might not directly address the anxiety related to financial stress.
Correct Answer is D
Explanation
A. Allowing the client to go to the bathroom independently may pose a safety risk, particularly if the labor progresses rapidly or if she experiences increased discomfort.
B. Assisting the client to the bathroom might not be advisable if she is in active labor, as her condition can change quickly, and she may need immediate access to care.
C. Offering the client a bedpan or urinal would allow for bladder emptying but may not address the urgency of her desire to ambulate.
D. Encouraging the client to hold off until she is further dilated is appropriate, as a full bladder can impede labor progression and lead to complications. This allows for monitoring and assessment of her condition, ensuring that she remains safe and that labor can continue effectively.
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