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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Administer a PRN antianxiety agent. - This should be a last resort due to potential side effects.
Non-pharmacological interventions are usually preferable.
B. Tell her no one is behind the curtain. - Arguing or contradicting her belief may escalate her agitation or confusion.
C. Transfer the client to another room. - Moving her to a new environment might exacerbate her confusion and distress.
D. Leave a night light on in her room. - This is a simple, non-intrusive intervention that can help reduce visual misinterpretations and provide comfort, potentially calming her agitation without confrontation or disruption.

A. Encourage the client to use the spirometer before receiving analgesia. B. Offer to reschedule the spirometer instruction until several hours later. C. Provide a PRN analgesic and then encourage use of the spirometer. D. Reassure the client that use of the incentive spirometer is not painful.

Correct Answer is A

Explanation

A. Encouraging the client to use the spirometer before analgesia is important as it helps prevent respiratory complications post-surgery. It's crucial for optimal recovery.
B. Rescheduling the spirometer instruction may delay a critical intervention for the client's postoperative care.
C. Providing a PRN analgesic before spirometer use might hinder the client from benefiting fully from the respiratory therapy.
D. Reassuring the client that the incentive spirometer is not painful doesn't address the client's request for analgesia before using it.

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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?

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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?