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 A
Explanation
This is the most important follow-up assessment for the PN to implement because it can detect signs of bleeding, infection, or shock that may result from the unsecured surgical dressing. The PN should monitor the client's blood pressure, pulse, temperature, and respiratory rate and report any abnormal changes.
Correct Answer is C
Explanation
"I realize that my life must go on, but sometimes I wonder why.”
Choice A rationale:
This statement may indicate frustration with physical limitations, which is common in older adults, especially after surgery. It does not necessarily indicate a need for bereavement counseling.
Choice B rationale:
Difficulty remembering simple things can be attributed to normal aging processes or other factors not directly related to bereavement.
Choice C rationale:
Expressing a sense of wondering "why”. after the loss of a spouse suggests ongoing grief and a potential need for bereavement counseling to process feelings and find meaning in life after the loss.
Choice D rationale:
Depending on children who live close-by is a common support mechanism for older adults and does not directly indicate a need for bereavement counseling.
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