The practical nurse (PN) is assisting with the 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?

The correct answer is B. Extend the leg and flex the foot.

Choice A rationale:

Massaging the calf and foot is not recommended as it could potentially dislodge a blood clot if one is present, which can be dangerous.

Choice B rationale:

Extending the leg and flexing the foot helps to relieve the cramp by stretching the muscles involved. This is a safe and effective method to alleviate muscle cramps.

Choice C rationale:

Checking the pedal pulse in the affected leg is important for assessing circulation but does not directly address the immediate discomfort of the cramp.

Choice D rationale:

Elevating the leg above the heart is generally used to reduce swelling and improve circulation but is not specifically effective for relieving muscle cramps.

: 3

The correct answers are Choice B and D:

Choice B: Report the appearance of the dressing to the charge nurse,

Choice D: Compress the drainage device before closing the tab.

Choice A rationale:

Documenting the appearance of the wound as inflamed is not appropriate. As a practical nurse, the immediate concern is to take action and report any concerning findings to the appropriate healthcare provider rather than just documenting it.

Choice B rationale:

Reporting the appearance of the dressing to the charge nurse is essential. The charge nurse or a more experienced healthcare provider needs to be informed of any abnormal findings or signs of infection for further evaluation and appropriate intervention.

Choice C rationale:

Removing the drainage device and applying a pressure dressing is not within the scope of practice for a practical nurse. These actions require a higher level of expertise and are typically performed by a registered nurse or healthcare provider.

Choice D rationale:

Compressing the drainage device before closing the tab is a correct action. This helps to ensure that the device is functioning properly, and there are no leaks or obstructions in the drainage system.

Choice E rationale:

Clamping the drainage tubing for the next four hours is not recommended unless specifically ordered by a healthcare provider. Clamping the drainage tubing without appropriate orders may disrupt the normal drainage process and cause complications.