A nurse is caring fora 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.
Irrigate indwelling urinary catheter with 50 mL of normal saline.
Apply warm compresses to the incision site.
Maintain bed rest for 2 days postoperatively.
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"}}
Rationale
• Irrigate indwelling urinary catheter with 50 mL normal saline: Following perineal prostatectomy, bladder spasms, pink urine, and a sensation of fullness can indicate catheter blockage from clots. Gentle irrigation with a small volume ensures catheter patency and relieves obstruction. The client’s decreasing urine output despite increased intake further supports the need for irrigation. Restoring flow prevents retention and reduces discomfort from bladder spasms.
• Apply warm compresses to the incision site: Heat increases vasodilation and can worsen postoperative bleeding in a highly vascular perineal area. A prostatectomy incision requires protection from excessive warmth to reduce hemorrhage risk. Additionally, warm compresses could increase swelling and discomfort.
• Maintain bed rest for 2 days postoperatively: Early ambulation is essential to prevent postoperative complications such as DVT, which is especially important given the client’s history of thrombosis. This client is already independently ambulating, which should be encouraged. Bed rest would increase clot formation risk and impair bowel function, worsening constipation and pain.
• Place a blanket roll under the client’s knees while in bed: Placing pillows or rolls under the knees promotes venous stasis and increases DVT risk, which is dangerous for this client with a past history of thrombosis. Knee flexion also strains the perineal surgical area and may increase pain. Maintaining legs flat encourages optimal circulation and reduces risk of clot formation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administer methylphenidate daily: Stimulant medications like methylphenidate are not appropriate for anorexia nervosa treatment, as they can suppress appetite and worsen weight loss. They are contraindicated in clients with this disorder.
B. Weigh the client twice a week: Weighing twice a week is insufficient for clients with anorexia nervosa. Daily, same-time, same-clothing weights are recommended to monitor progress and detect potential medical complications associated with malnutrition.
C. Focus conversations around food at mealtimes: Focusing on food can increase anxiety and reinforce preoccupations with eating. Instead, conversations should be neutral or supportive, promoting a calm and therapeutic mealtime environment.
D. Inform the client of the specific duration of meals: Setting clear expectations for meal duration helps reduce anxiety, provides structure, and supports adherence to nutritional rehabilitation. It is an effective intervention in the care plan for clients with anorexia nervosa.
Correct Answer is A
Explanation
A. Syphilis: Syphilis is a nationally notifiable disease in the United States. Healthcare providers are required to report cases to local or state public health authorities to facilitate disease tracking, outbreak management, and public health interventions.
B. Trichomoniasis: Trichomoniasis is not a nationally notifiable disease. While it is a common sexually transmitted infection, reporting is not required by law at the national level, though some states may have local reporting requirements.
C. Genital herpes: Genital herpes is not nationally reportable because it is highly prevalent and often managed in outpatient settings without mandatory reporting. Surveillance focuses on population studies rather than individual case reporting.
D. Human papillomavirus (HPV): HPV infections are not nationally notifiable. Although HPV is common and associated with cancers, individual cases are not reported to public health authorities. Reporting is limited to cancer registries for HPV-related malignancies.
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