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 D
Explanation
A. Comprehension of simple commands might be seen in older infants or toddlers but is not specifically correlated with an infant searching for a fallen toy.
B. Ability to place objects in a container typically occurs in the sensorimotor stage but is not directly related to the scenario of an infant searching for a fallen toy.
C. Visible or audible separation anxiety is more common in younger infants when separated from their caregivers and doesn't directly correlate with an infant searching for an object.
D. Exploration beyond caregiver presence is characteristic of the sensorimotor stage in Piaget's theory, where infants develop object permanence and start to explore and search for objects beyond their immediate vicinity, such as a fallen toy.
Correct Answer is A
Explanation
The picture shows that the newly hired PN is about to make a serious error by adding the medication directly to the feeding bag, which can cause clogging, contamination, or inaccurate dosing of the medication. The PN should demonstrate how to administer medication via a feeding tube correctly, which involves stopping the feeding, flushing the tube with water, instilling the medication, flushing again, and resuming the feeding.
The other options are not correct because:
B. Confirming that the medication is only administered once daily is not relevant or helpful, as it does not address the error or teach the correct technique of administering medication via a feeding tube.
C. Determining if the medication is compatible with the solution is not necessary or appropriate, as the medication should not be mixed with the solution in the first place, but given separately through the feeding tube.
D. Offering to assist in calculating the rate of flow for the mixture is not relevant or helpful, as there should be no mixture of medication and solution in the feeding bag, but separate administration of each through the feeding tube.
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