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?
Review the client's expectations of elimination after surgery.
Verify that the client had nothing by mouth (NPO) for the past 24 hours.
Ask the client if he finished the bowel sterilization prescription.
Determine if this is the first indwelling catheter the client has had.
The Correct Answer is A
This is the best action for the PN to implement because it addresses the client's question and provides an opportunity to educate the client about the fecal diversion surgery and its outcomes. The PN should review the type, location, and appearance of the surgical opening (stoma) and explain how it will affect the client's elimination and body image.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The PN should not prioritize bringing a glucometer to the room in this situation. The client's unresponsiveness indicates a potential medical emergency that requires immediate action, and checking blood glucose levels is not the primary concern at this moment.
Choice C rationale:
Feeling for a carotid pulse is an essential step in assessing the client's circulation. However, it is not the first priority when the client is unresponsive. The PN should focus on obtaining emergency help first to ensure timely intervention.
Choice D rationale:
Checking the blood pressure can provide valuable information about the client's condition, but it is not the most critical step when dealing with an unresponsive client. Promptly seeking emergency assistance is more important to address the immediate concern.
Correct Answer is D
Explanation
d. Escort the client to a calm and quiet place.
The PN should use a calm and firm approach to de-escalate the situation and remove the client from the stressful environment. This can help prevent further agitation and potential violence.
The other options are not correct because:
- Instructing a UAP to stay with the client may not be effective or safe, as the UAP may not have the skills or training to handle an agitated client.
- Notifying the client's healthcare provider is not a priority action, as it does not address the immediate safety of the client and others.
- Administering a PRN medication for agitation may be indicated, but it is not the first action. The PN should try non- pharmacological interventions first, unless there is an imminent risk of harm.
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