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A nurse is caring for a postoperative client following a perineal prostatectomy.

Exhibits

For each potential provider’s prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Potential Order:.

A.

Apply warm compresses to the incision site.

B.

Maintain bed rest for 2 days postoperatively.

C.

Irrigate indwelling urinary catheter with 50 mL of normal saline.

D.

Administer enema to relieve constipation.

E.

Place a blanket roll under the client’s knees while in bed.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"B"}}

The correct answer is choice A. Applying warm compresses to the incision site is anticipated for the client, as it can help reduce swelling and pain.

The other choices are contraindicated for the following reasons:

  • Choice B: Maintaining bed rest for 2 days postoperatively is contraindicated, as it can increase the risk of complications such as deep vein thrombosis, pulmonary embolism, and pneumonia. The client should be encouraged to ambulate as soon as possible after surgery.
  • Choice C: Irrigating indwelling urinary catheter with 50 mL of normal saline is contraindicated, as it can introduce bacteria into the bladder and cause infection. The catheter should be kept patent and draining without irrigation unless there is a specific order from the provider.
  • Choice D: Administering enema to relieve constipation is contraindicated, as it can increase the pressure in the pelvic area and cause bleeding or damage to the surgical site. The client should be given stool softeners and laxatives to prevent constipation.
  • Choice E: Placing a blanket roll under the client’s knees while in bed is contraindicated, as it can impair blood circulation and cause thrombophlebitis. The client should avoid flexing the knees excessively and elevate the legs slightly when lying down.


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Related Questions

Correct Answer is D

Explanation

The correct answer is d. “Your desire to be an organ donor must be documented in writing.”

Rationale for Choice a:

  • Statement:“Your name cannot be removed once you are listed on the organ donor list.”
  • Rationale:This statement is incorrect.Individuals have the right to change their minds about organ donation at any time.They can have their names removed from the organ donor list by contacting the appropriate registry or organization.It's essential for nurses to provide accurate information to ensure informed consent and respect for patient autonomy.

Rationale for Choice b:

  • Statement:“You must be at least 21 years of age to become an organ donor.”
  • Rationale:This statement is also incorrect.The age requirement for organ donation varies by jurisdiction.In many places,individuals under 18 years of age can register as organ donors with parental consent.Nurses should be familiar with local regulations to provide accurate guidance.

Rationale for Choice c:

  • Statement:“I cannot be a witness for your consent to donate.”
  • Rationale:While it's true that nurses generally cannot act as witnesses for organ donation consent,the focus of the response should be on directing the client to the appropriate channels for documentation.Nurses can play a role in facilitating the process by providing information and resources to clients who express interest in organ donation.

Rationale for Choice d:

  • Statement:“Your desire to be an organ donor must be documented in writing.”
  • Rationale:This is the correct response.To ensure clarity and legal validity,organ donation preferences must be documented in writing.This documentation can be done through various means,such as registering with an organ donor registry,indicating preferences on a driver's license,or completing an advance directive.Nurses should emphasize the importance of written documentation to protect the client's wishes.

Correct Answer is C

Explanation

This is because a peak flow meter measures how fast you can push air out of your lungs when you blow out as hard and as fast as you can. This is called peak expiratory flow rate (PEFR) or peak expiratory flow (PEF). It shows how open the airways are in the lungs and can help detect early signs of worsening asthma.

Choice A is wrong because maintaining a semi-Fowler’s position during testing is not necessary. You can sit or stand up straight, but make sure you do it the same way each time.

Choice B is wrong because placing tongue on the mouthpiece of the meter can block the air flow and affect the accuracy of the measurement. You should close your lips tightly on the mouthpiece instead.

Choice D is wrong because recording the average of the readings is not recommended.

You should record the highest of the three readings on a sheet of paper, calendar or in your asthma diary. This is your daily peak flow.

Normal ranges for peak flow vary depending on age, height, gender and race. You can use a chart or calculator to find out your predicted normal peak flow based on these

factors. However, it is more important to find out your personal best peak flow by performing peak flow testing twice a day for two weeks when your asthma is under good control. Your personal best peak flow will be used to create your asthma action plan with your healthcare provider.

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