A nurse is planning care for a client who was admitted to the unit for pneumonia.

Exhibits

The nurse is planning care for the client.

Complete the following sentence by using the lists of options.

After providing perineal care and donning sterile gloves, the nurse should first
dropdown
followed by
dropdown

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

After providing perineal care and donning sterile gloves, the nurse should first lubricate the catheter tip followed by insert the catheter until urine flows.

Rationale:

Lubricating the catheter tip ensures smooth insertion and minimizes discomfort or trauma to the urethra.
Inserting the catheter until urine flows confirms proper placement before advancing slightly more to ensure complete drainage.

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Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"E"}

Explanation

The client is most at risk of developing atelectasis and paralytic ileus.

Rationale:

Atelectasis – The client has shallow breathing and received IV morphine, which can suppress respiratory effort. Postoperative clients, especially those with abdominal surgery, are at higher risk for atelectasis due to pain-related splinting and immobility.
Paralytic Ileus – The client has hypoactive bowel sounds at both assessments, indicating delayed return of bowel function postoperatively. This is common after abdominal surgery, especially with opioid use, and can lead to paralytic ileus.

Urinary tract infection (UTI) – The client has voided 350 mL of clear yellow urine, indicating normal urinary function post-catheter removal.
Delayed wound healing – There is no sign of wound complications (dressing remains dry and intact).
Deep vein thrombosis (DVT) – No signs of unilateral swelling, redness, or pain, and the client is wearing sequential compression devices to prevent DVT.

A. Rhythmic respirations B. Absent cry C. Resisting care D. Relaxed posturing

Correct Answer is C

Explanation

A. "Rhythmic respirations." Normal, rhythmic breathing is not typically associated with pain. Pain may cause labored, irregular, or rapid breathing.
B. "Absent cry." The FLACC scale assesses crying as an indicator of pain. However, an absent cry does not suggest pain. A strong, continuous cry or moaning may indicate discomfort.
C. "Resisting care." Clients with pain often resist movement, care, or interventions due to discomfort or distress. This is a key indicator of pain in the FLACC scale (Activity or Consolability sections).
D. "Relaxed posturing." A relaxed posture suggests comfort, while pain often leads to rigid or tense positioning.

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Rationale:

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in a medical-surgical unit. Exhibits Drag words from the choices below to fill in each blank in the following sentence. The client is most at risk of developing dropdownanddropdown

Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"E"}

Explanation

A nurse is using the faces, legs, activity, cry, consolability (FLACC) scale to assess the need for PRN pain medication for a client who has cognitive impairment. Which of the following findings should the nurse identify as an indication the client is experiencing pain?

Correct Answer is C

Explanation

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