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 C
Explanation
The correct answer is C. Oriented to person only.
Choice A rationale:
A blood pressure of 144/84 mmHg is slightly elevated but not critically high. While it is important to monitor, it does not immediately impact the instructions for morning care.
Choice B rationale:
An oxygen saturation measurement of 95 to 96% is within the normal range and indicates adequate oxygenation. This is important to monitor but does not require specific changes to morning care instructions.
Choice C rationale:
Being oriented to person only indicates a significant alteration in the client’s cognitive status, which is crucial for the UAP to be aware of. This affects the client’s ability to understand and follow instructions, and may require additional supervision and safety measures during care.
Choice D rationale:
A urinary output of 50 mL/hour is within the normal range (typically 30-50 mL/hour is considered adequate). While it is important to monitor, it does not necessitate immediate changes to morning care instructions.
: 1
Correct Answer is C
Explanation
The correct answer is choice C. Consult with the client about the reasons for his refusal to be weighed.
Choice A rationale:
Including "Noncompliance”. as a priority problem in the client's plan of care assumes the client's refusal to be weighed is intentional and willfully disobedient. This may not be the case, and labeling the client as noncompliant could create a negative atmosphere, hindering effective communication and care.
Choice B rationale:
Advising the UAP to re-attempt the daily weight after the client eats breakfast does not address the underlying reason for the client's refusal. Additionally, there is no evidence suggesting that weighing the client after breakfast will improve the situation.
Choice C rationale:
Consulting with the client about the reasons for his refusal to be weighed is the most appropriate action. Open communication with the client can help identify any concerns or fears related to the weighing process. By understanding the client's perspective, the healthcare team can work together to find a solution that ensures the client's cooperation with the weight monitoring.
Choice D rationale:
Calculating the client's weight based on the 24-hour fluid intake and output is not a reliable method for obtaining an accurate weight measurement. Fluid volume overload can lead to fluid retention and may not accurately reflect the client's true weight.
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