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. Documenting the client's understanding is important, but correcting the misconception about the use of the eye drops is the immediate priority.
B. Reminding the client about the intended action of the eye drops helps clarify their purpose in managing glaucoma by reducing intraocular pressure.
C. Assessing the intensity of eye pain using a numerical pain scale might not be necessary in this context as the client's misconception about the eye drops needs correction.
D . Clarifying that eye pain in glaucoma is uncommon does not address the client's misunderstanding about the purpose of the pilocarpine eye drops.
Correct Answer is A
Explanation
A. Assessing the client's mental status is crucial before administering zolpidem, a sleep aid, as it helps ensure the client is alert enough to take the medication safely. This assessment includes evaluating the client's level of consciousness, orientation, and cognitive function.
B. Monitoring body temperature might be necessary in certain clinical situations, but it's not directly relevant before administering zolpidem unless there are specific concerns related to body temperature.
C. Assessing bowel sounds is an important part of a comprehensive physical assessment, but it's not directly tied to the administration of a sleep aid like zolpidem.
D. Evaluating skin integrity is important for overall patient care, but it's not specifically linked to the assessment needed before administering a sleep medication like zolpidem.
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