Choice A Reason:

Refrigerating the solution before irrigation is not recommended. The solution should be at room temperature to avoid causing discomfort or vasoconstriction, which can impede the healing process.

Choice B Reason:

Administering an analgesic medication 5 minutes before starting irrigation is correct. This action helps manage the client’s pain during the procedure, ensuring comfort and compliance.

Choice C Reason:

Using one pair of gloves for both dressing removal and irrigation is incorrect. The nurse should use separate pairs of gloves to prevent cross-contamination and maintain aseptic technique.

Choice D Reason:

Using a syringe with a catheter for wound irrigation is correct practice. This method allows for controlled and directed irrigation, ensuring the wound is properly cleaned.

Choice A Reason:

Moving quickly to a position in front of the client is not recommended. This action could result in both the nurse and the client falling, potentially causing injury to both parties.

Choice B Reason:

Remaining upright as the client falls toward them is incorrect. This action does not provide adequate support or control, increasing the risk of injury to the client.

Choice C Reason:

Allowing the client to slide down their outstretched leg is the correct action. This technique helps control the fall and minimizes the risk of injury by providing a controlled descent to the floor.

Choice D Reason:

Placing their arms around the client to prevent the fall is not advisable. This action can lead to both the nurse and the client falling, which could result in injuries.

Choice A Reason

Allowing the client to hear running water while attempting to void can sometimes help stimulate urination through the power of suggestion. This method is non-invasive and can be effective for some patients. However, it may not be sufficient for a client who is 6 hours postoperative and experiencing significant difficulty voiding. In such cases, more direct intervention may be necessary to prevent complications like bladder distension or urinary retention.

Choice B Reason

Encouraging fluid intake up to 1,000 mL daily is generally good advice for maintaining hydration and promoting urinary function. However, in the immediate postoperative period, especially within the first 6 hours, the focus should be on addressing the acute issue of urinary retention. Increasing fluid intake alone may not resolve the problem and could potentially exacerbate bladder distension if the client is unable to void.

Choice C Reason

Providing the client a bedpan while lying supine is a practical approach to assist with urination, especially if the client is unable to get out of bed. However, the supine position is not the most conducive for voiding, as it can make it more difficult for the bladder to empty completely. This method might not be effective for a client experiencing significant difficulty voiding postoperatively.

Choice D Reason

Inserting an indwelling urinary catheter and connecting it to gravity drainage is the most appropriate action for a client who is 6 hours postoperative and having difficulty voiding. This intervention directly addresses the issue of urinary retention by ensuring that the bladder is emptied, thereby preventing complications such as bladder distension, urinary tract infections, and potential kidney damage. It is a standard practice in postoperative care when less invasive methods are ineffective.

Choice A Reason

Lifting the client to the bed with assistance is not recommended during a seizure. Moving the client can increase the risk of injury to both the client and the nurse. The primary focus should be on ensuring the client’s safety by preventing injury from nearby objects and allowing the seizure to run its course.

Choice B Reason

Turning the client onto their back is not advisable during a seizure. This position can increase the risk of airway obstruction and aspiration. Instead, the client should be turned onto their side to maintain an open airway and allow any secretions to drain from the mouth, reducing the risk of aspiration.

Choice C Reason

Clearing the nearby area of furniture is the most appropriate action. This helps to prevent the client from injuring themselves on hard or sharp objects during the seizure. Ensuring a safe environment is a key priority in managing a seizure, as it minimizes the risk of physical harm.

Choice D Reason

Placing a tongue depressor in the client’s mouth is an outdated and dangerous practice. It can cause injury to the client’s teeth, mouth, or airway. There is also a risk of the client biting down and breaking the depressor, leading to choking hazards. Modern seizure management guidelines strongly advise against placing any objects in the client’s mouth during a seizure.

Choice A Reason

Eyelashes that curl slightly outward are a normal finding in an eye assessment. This natural curl helps protect the eyes from debris and sweat, and it also aids in the distribution of tears across the eye surface. Eyelashes that curl outward are typical and expected in a healthy individual.

Choice B Reason

Corneas with an opaque appearance are not a normal finding. The cornea should be clear and transparent, allowing light to pass through to the retina. An opaque cornea can indicate various conditions such as corneal edema, scarring, or infection. Therefore, this finding would be abnormal and warrant further investigation.

Choice C Reason

Eyelids that blink involuntarily 30 to 35 times per minute are not within the normal range. The average blink rate for a healthy adult is approximately 15 to 20 times per minute. A significantly higher blink rate could indicate an underlying condition such as dry eye syndrome, blepharospasm, or other neurological issues.

Choice D Reason

Pupils that are 8 to 9 mm in diameter are abnormally large. The normal pupil size ranges from 2 to 4 mm in bright light and 4 to 8 mm in dim light. Pupils that are consistently larger than this range could indicate a condition such as mydriasis, which can be caused by various factors including medications, trauma, or neurological disorders.

Choice A Reason: Bounding Pulses

Bounding pulses are typically associated with increased cardiac output or high blood pressure, rather than active bleeding. In the context of postoperative care, bounding pulses might indicate fluid overload or other cardiovascular issues, but they are not a primary sign of active bleeding.

Choice B Reason: Restlessness

Restlessness is a common sign of hypovolemia, which can occur due to active bleeding. When a patient is losing blood, their body may respond with anxiety or restlessness as a result of decreased oxygen delivery to tissues and organs. This is a compensatory mechanism to maintain perfusion. Restlessness, along with other signs such as tachycardia and hypotension, can indicate significant blood loss and the need for immediate intervention.

Choice C Reason: Warm Skin

Warm skin is generally not associated with active bleeding. In fact, patients who are actively bleeding may present with cool, clammy skin due to peripheral vasoconstriction as the body attempts to maintain core temperature and blood flow to vital organs. Warm skin might be observed in other conditions, such as fever or inflammation, but it is not a typical sign of active bleeding.

Choice D Reason: Brisk Capillary Refill

Brisk capillary refill, which is a capillary refill time of less than 2 seconds, indicates good peripheral perfusion and is not a sign of active bleeding. In contrast, a delayed capillary refill time (greater than 2 seconds) can be a sign of poor perfusion, which might occur in the case of significant blood loss. Therefore, brisk capillary refill is not indicative of active bleeding.

Choice A Reason: I will walk three times per week.

Walking is a weight-bearing exercise, which is crucial for maintaining bone density and reducing the risk of osteoporosis. Regular physical activity, especially weight-bearing exercises like walking, helps stimulate bone formation and slows down bone loss. The National Osteoporosis Foundation recommends at least 30 minutes of weight-bearing exercise on most days of the week to help prevent osteoporosis

Avoiding sun exposure is not advisable for reducing the risk of osteoporosis. Sunlight is a natural source of vitamin D, which is essential for calcium absorption and bone health. While excessive sun exposure can be harmful, moderate exposure helps the body produce sufficient vitamin D. Therefore, avoiding sun exposure entirely can lead to vitamin D deficiency, increasing the risk of osteoporosis.

Choice C Reason: I will take 250 milligrams of calcium once per day.

The recommended daily intake of calcium for older adults is significantly higher than 250 milligrams. For adults aged 51 and older, the National Institutes of Health recommends 1,200 milligrams of calcium per day. Adequate calcium intake is vital for maintaining bone health and preventing osteoporosis. Therefore, taking only 250 milligrams of calcium per day is insufficient to meet the body’s needs.

Choice D Reason: I will decrease my intake of dairy products.

Dairy products are a primary source of calcium, which is essential for bone health. Reducing the intake of dairy products can lead to inadequate calcium intake, increasing the risk of osteoporosis. Instead, older adults should ensure they consume enough dairy or other calcium-rich foods to meet their daily calcium requirements.

The correct answer is b. “We can discuss several scheduling options for monitoring your blood glucose.”

Choice A Reason

“You should be fine as long as you check your blood glucose before eating.” This response is not ideal because it oversimplifies the complexity of managing insulin-dependent diabetes. Blood glucose monitoring should be done at various times throughout the day, including before meals, after meals, and possibly before bedtime, to ensure proper management and avoid complications. Limiting checks to just before meals may not provide a comprehensive picture of the client’s glucose levels.

Choice B Reason

“We can discuss several scheduling options for monitoring your blood glucose.” This response is the most appropriate as it acknowledges the client’s concern and offers a collaborative approach to finding a solution. It allows the nurse to tailor the blood glucose monitoring schedule to fit the client’s busy lifestyle, ensuring better adherence and management of diabetes. This approach also empowers the client by involving them in their care plan.

Choice C Reason

“You should reorganize your schedule around your blood glucose monitoring.” While it is important for the client to prioritize their health, this response may come across as dismissive of the client’s busy schedule. It does not offer practical solutions or flexibility, which are crucial for long-term adherence to diabetes management. A more supportive and collaborative approach would be more effective.

Choice D Reason

“Your provider will set up a schedule for when you should monitor your blood glucose.” This response places the responsibility solely on the healthcare provider and does not address the client’s immediate concern about fitting blood glucose monitoring into their busy schedule. While the provider’s input is important, the nurse should also offer immediate support and practical solutions. Collaborative planning is key to effective diabetes management.

Choice A Reason

Bending at the waist to pick up the box is not recommended as it can put excessive strain on the lower back. Proper lifting techniques involve bending at the knees and hips, not the waist, to use the stronger muscles of the legs and reduce the risk of back injury. This method helps maintain the natural curve of the spine and distributes the load more evenly.

Choice B Reason

When lifting the box, keeping it close to the body is the most appropriate action. This technique reduces the lever arm distance, thereby decreasing the strain on the back muscles and spine. Holding the load close to the body ensures better control and stability, making it easier to lift and carry the box safely.

Choice C Reason

Keeping the feet close together when lifting a box is not advisable. A wide stance, with feet shoulder-width apart, provides better balance and stability. This position allows for a more secure lift and reduces the risk of losing balance or straining muscles during the lifting process.

Choice D Reason

Relaxing the abdominal muscles to prevent straining the back is incorrect. Engaging the core muscles, including the abdominals, provides additional support to the spine and helps maintain proper posture during lifting. Tightening the abdominal muscles can help stabilize the torso and reduce the risk of back injury.

Choice A Reason: Seat the client in a chair for 30 minutes prior to applying the stockings.

Seating the client in a chair for 30 minutes before applying the stockings is not necessary. In fact, it is recommended to apply antiembolic stockings while the client is in a supine position to prevent blood from pooling in the legs. This ensures that the stockings fit properly and provide the intended compression to promote venous return.

Choice B Reason: Measure the length of the client’s leg from the heel to the gluteal fold.

Measuring the length of the client’s leg from the heel to the gluteal fold is essential for ensuring the correct fit of knee-length antiembolic stockings. Proper measurement helps in selecting the right size, which is crucial for the stockings to be effective in preventing deep vein thrombosis (DVT) by promoting blood circulation. Incorrectly sized stockings may either be too tight, causing discomfort and impaired circulation, or too loose, failing to provide adequate compression.

Choice C Reason: Instruct the client to point their toes while applying the stockings.

Instructing the client to point their toes while applying the stockings is not a standard practice. Instead, the nurse should gather the stocking material and gently roll it over the foot and up the leg, ensuring it is evenly distributed and free of wrinkles. This method helps in applying the stockings smoothly and effectively without causing discomfort or improper fit.

Choice D Reason: Roll the top of the client’s stockings down to just below the knee.

Rolling the top of the stockings down to just below the knee is incorrect and can lead to a tourniquet effect, which can impede blood flow and increase the risk of DVT. The stockings should be applied smoothly and should extend to their full length without being rolled down to ensure proper compression and effectiveness.