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 B
Explanation
A. Urinary frequency. - Urinary frequency is not a typical symptom indicative of hypoglycemia.
B. Tachycardia. - Tachycardia, an increased heart rate, can be a sign of hypoglycemia as the body responds to low blood sugar by increasing the heart rate to compensate.
C. Elevated temperature. - Elevated temperature is not typically associated with hypoglycemia; it might suggest an infection or other issues.
D. Hypertension. - Hypertension, or high blood pressure, is not a typical sign of hypoglycemia; it might indicate other health conditions or issues.
Correct Answer is A
Explanation
A. "May I sit with you for a while?" - This response offers companionship and emotional support without pushing the resident to engage in an activity or prying into his feelings. It respects his desire for solitude while providing the option for company if he wishes.
B. "Why do you want to stay in your room today?" - This might be perceived as intrusive and pushy, potentially making the resident more withdrawn.
C. "Come into the recreation area. We have your favorite card game and I will play it with you." - While well-intentioned, this suggestion may not align with the resident's current emotional state or desire for solitude.
D. "I know you are sad about not seeing your family as often, but they are visiting as much as they can." - This response acknowledges the resident's feelings but may not address his immediate need for companionship or support.
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