A nurse is caring for a postoperative client following a perineal prostatectomy.
For each potential provider’s prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.
Potential Order:.
Apply warm compresses to the incision site.
Maintain bed rest for 2 days postoperatively.
Irrigate indwelling urinary catheter with 50 mL of normal saline.
Administer enema to relieve constipation.
Place a blanket roll under the client’s knees while in bed.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is because the nurse should assess the client’s level of mobility, strength, and coordination before repositioning them to prevent injury and promote comfort. The nurse should also use appropriate assistive devices, such as a drawsheet, a trapeze bar, or a mechanical lift, to facilitate safe repositioning and reduce the risk of skin breakdown and pressure ulcers.
Choice A is wrong because raising the side rails on both sides of the client’s bed during repositioning can increase the risk of falls and entrapment.
The nurse should only raise the side rail on the opposite side of the bed from where they are working and lower it when they are done.
Choice B is wrong because repositioning the client without assistive devices can cause strain and injury to both the nurse and the client.
The nurse should use assistive devices that are appropriate for the client’s condition and weight.
Choice C is wrong because discussing the client’s preferences for determining a repositioning schedule is not a priority action when preparing to reposition a client who had a stroke.
The nurse should follow the facility’s protocol for repositioning frequency, which is usually every 2 hours, and adjust it according to the client’s needs and comfort.
The nurse should also involve the client in the care plan and respect their preferences whenever possible.
Correct Answer is A
Explanation
This is because collaboration is one of the most effective conflict-resolution strategies in nursing, as it involves finding a mutually beneficial solution that satisfies both parties and improves the quality of care. Collaboration can also foster trust, respect, and teamwork among nurses, which can boost morale and efficiency.
Choice B is wrong because telling the nurses that the assignments will be more equitable in the future does not address the root cause of the conflict or involve the nurses in the decision-making process.
It also implies that the charge nurse admits to being unfair, which can damage their credibility and authority.
Choice C is wrong because asking each nurse to take turns making the assignments does not resolve the conflict, but rather avoids it. Avoidance is one of the least effective conflict management strategies in nursing, as it results in not addressing the issue or finding common ground.
Avoidance can also lead to resentment, frustration, and poor communication among nurses.
Choice D is wrong because arranging for the nurses to have as few shifts together as possible also does not resolve the conflict, but rather accommodates it. Accommodation is another ineffective conflict management strategy in nursing, as it involves giving in to one party’s demands or preferences at the expense of another’s.
Accommodation can also create a sense of inequality, injustice, and dissatisfaction among nurses.
Normal ranges for conflict-resolution strategies in nursing are not applicable, as different situations may require different approaches. However, some general guidelines are to use collaboration when both parties have important goals or interests, compromise when both parties have some common ground or willingness to give up something, competition when one party has a clear advantage or authority, avoidance when the conflict is trivial or temporary, and accommodation when one party values harmony or relationships more than their own goals or interests.
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