A nurse is planning care for a male client who is postoperative following a hernia repair. Which of the following actions should the nurse include in the plan?
Elevate the client's scrotum on a pillow.
Restrict fluids to 1,200 mL per day.
Place a warm pack on the incisional area.
Encourage the client to sit to void.
The Correct Answer is A
Rationale:
A. Elevate the client's scrotum on a pillow: After hernia repair, scrotal elevation helps reduce swelling and promote venous return, minimizing postoperative edema and discomfort. Supporting the scrotum with a pillow or rolled towel also decreases tension on the incision site, enhancing comfort and healing.
B. Restrict fluids to 1,200 mL per day: Fluid restriction is not indicated for clients following hernia repair unless there is a concurrent condition such as renal or cardiac impairment. Adequate hydration is essential to prevent constipation and promote tissue recovery after surgery.
C. Place a warm pack on the incisional area: Warm packs should be avoided immediately after surgery because they can increase local blood flow and risk of bleeding at the incision site. Cold packs may be used instead to reduce swelling and provide comfort.
D. Encourage the client to sit to void: Male clients are encouraged to stand when voiding to reduce intra-abdominal pressure on the surgical site. Sitting to void may increase pressure on the repaired area, potentially causing discomfort or strain on the incision.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Mottled skin: Mottling is typically a late sign of poor perfusion or approaching death and does not indicate pain. It reflects circulatory changes rather than discomfort requiring analgesia.
B. Constricted pupils: Constricted pupils may result from certain medications or neurological changes, but they are not a reliable indicator of pain. Pupillary changes alone do not guide pain management.
C. Restlessness: Restlessness is a common manifestation of pain in clients receiving palliative care, especially when verbal communication is limited. Administering prescribed pain medication can help alleviate discomfort and improve comfort.
D. Cheyne-Stokes respirations: This irregular breathing pattern occurs in advanced illness or near end-of-life and is not an indicator of pain. It reflects neurological or metabolic changes rather than discomfort requiring analgesia.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"}}
Explanation
Rationale:
• Polyhydramnios: Excess amniotic fluid stretches the uterus, increasing the risk of uterine atony postpartum because the uterine muscle fibers are overly distended and cannot contract effectively.
• High parity: Multiple prior pregnancies weaken uterine muscle tone over time, predisposing the client to uterine atony after delivery, as the uterus may not contract adequately to control bleeding.
• Prolonged rupture of membranes: Extended rupture (over 24 hours) increases the risk of ascending infections such as chorioamnionitis or endometritis, as the protective barrier of the amniotic sac is compromised.
• Prenatal anemia: Although anemia does not directly cause infection, it reflects a reduced physiological reserve and may predispose the client to infection complications due to decreased oxygen delivery and impaired immune response.
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