Exhibits

Select the 2 actions the nurse should prepare to take for the client.

Encourage oral fluid intake.

Administer an enema.

Irrigate indwelling catheter with 500 mL of fluid.

Assist the client with a sitz bath.

Encourage prolonged dangling before ambulation.

Answer and Explanation

Correct Answer : A,B

A. Encourage oral fluid intake. The client has pink urine, which may indicate mild hematuria. While the urine output is adequate, increasing fluid intake can help dilute the urine, reduce irritation, and promote overall hydration. Additionally, increased fluid intake can aid in softening stool and preventing further constipation.
B. Administer an enema. The client reports abdominal cramping and a small, hard, painful bowel movement, indicating constipation. Postoperative clients are at risk for constipation due to decreased mobility, opioid pain medications, and anesthesia effects. Administering an enema can help relieve discomfort and promote bowel movements.
C. Irrigate indwelling catheter with 500 mL of fluid. The client's urinary catheter is intact, and there is a consistent urine output of 100 mL/hr. The presence of pink urine does not indicate obstruction requiring catheter irrigation. Irrigation with such a large volume could introduce unnecessary risk and is not warranted at this time.
D. Assist the client with a sitz bath. Sitz baths are typically used for perineal discomfort, such as after perineal surgery, hemorrhoids, or childbirth. There is no indication in the nurse’s notes that the client has perineal pain or a condition requiring a sitz bath.
E. Encourage prolonged dangling before ambulation. The client is already ambulating independently, indicating no significant issues with orthostatic hypotension or weakness. Encouraging prolonged dangling is unnecessary and could delay mobility, which is essential for preventing complications such as constipation and venous thromboembolism.

Nursing Test Bank

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Correct Answer is D

Explanation

A. "You can apply counterpressure to your back with each position change." Counterpressure is commonly used for pain relief during labor, particularly for back labor caused by fetal positioning. It is not a typical nonpharmacological intervention for post-cesarean pain management.
B. "You should change positions as little as possible." Frequent position changes help promote circulation, prevent complications such as deep vein thrombosis, and reduce stiffness. Encouraging mobility with proper pain management is essential for recovery after a cesarean birth.
C. "You should use patterned-paced breathing when changing positions." Patterned-paced breathing is a technique used during labor for pain management and relaxation. While controlled breathing may help with general discomfort, it is not the most effective strategy for post-cesarean pain during movement.
D. "You can splint the incision with a pillow when changing positions." Holding a pillow against the incision site provides support, reduces strain on the abdominal muscles, and minimizes pain when moving, coughing, or laughing. This is a well-established method for post-cesarean pain relief.

A. Document the infiltration. B. Stop the infusion. C. Elevate the arm. D. Apply a warm compress.

Correct Answer is B

Explanation

A. "Document the infiltration." While documentation is necessary, it is not the first action the nurse should take. Immediate intervention is required to prevent further complications from IV infiltration, such as tissue damage or fluid leakage into surrounding tissues.
B. "Stop the infusion." The first action the nurse should take is to stop the IV infusion to prevent further infiltration of fluid into the surrounding tissues. Continuing the infusion could worsen swelling, discomfort, and potential tissue injury.
C. "Elevate the arm." Elevating the affected extremity can help reduce swelling by promoting fluid reabsorption, but this should be done after stopping the infusion to prevent additional fluid from accumulating in the tissues.
D. "Apply a warm compress." A warm compress can help promote absorption of non-vesicant solutions, while a cold compress is preferred for certain medications to reduce swelling and pain. However, applying a compress should only be done after stopping the infusion and assessing the severity of infiltration.

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Exhibits Select the 2 actions the nurse should prepare to take for the client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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Exhibits

Select the 2 actions the nurse should prepare to take for the client.