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 B
Explanation
This is because cotton socks can help keep the feet dry and prevent infections. Wearing clean socks every day can also prevent blisters and injuries from friction.
Choice A is wrong because soaking feet twice daily can make the skin too soft and prone to injury. It can also wash away natural oils that protect the skin.
Choice C is wrong because rounding the edges of toenails when trimming can cause ingrown nails, which can lead to infection and pain. Toenails should be trimmed straight across and filed smoothly.
Choice D is wrong because using moisturizing lotion between the toes can create a moist environment that promotes fungal growth. Moisturizing lotion should be applied to the rest of the feet, but not between the toes.
Some other foot care guidelines for people with diabetes are:
• Inspect your feet daily and look for signs of injury, such as scrapes, cuts, blisters, etc.
• Wash your feet every day in warm water with mild soap.
Hot water and harsh soaps can damage your skin. Check the water temperature with your fingers or elbow before putting your feet in.
• Don’t walk barefoot.
Protect your feet from heat and cold. Wear appropriate-fitting shoes to avoid injury and blisters.
• See a doctor to remove corns or calluses (don’t do it yourself). Don’t use chemical wart removers, razor blades, corn plasters, or liquid corn or callus removers.
• Don’t sit with your legs crossed or stand in one position for long periods of time.
• See your doctor regularly for foot exams and report any problems or changes in your feet. References:
Correct Answer is A
Explanation
This is because at 12 weeks of gestation, the uterus is still low in the pelvis and the fetal heart tones are best audible through the fetal back, which is usually located just above the symphysis pubis. The fetal heart rate at this stage is normally between 120 and 180 beats per minute.
Choice B is wrong because measuring the fundal height is not necessary to determine the placement of the ultrasound stethoscope at 12 weeks of gestation. The fundal height is usually measured from 20 weeks of gestation onwards to assess fetal growth and estimate gestational age.
Choice C is wrong because placing the client in a side-lying position prior to assessing the fetal heart rate is not required at 12 weeks of gestation. This position may be helpful later in pregnancy to improve maternal blood flow and oxygen delivery to the fetus, especially if there are signs of fetal distress or hypoxia.
Choice D is wrong because performing Leopold maneuvers prior to auscultating the fetal heart rate is not appropriate at 12 weeks of gestation.
Leopold maneuvers are a series of four steps to palpate the abdomen and determine the fetal position, presentation, lie, and engagement. They are usually performed after 24 weeks of gestation when the fetus is large enough to be felt through the abdominal wall.
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