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.

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Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A,C"},"C":{"answers":"C"},"D":{"answers":"C"},"E":{"answers":"B"},"F":{"answers":"A,B"},"G":{"answers":"B,C"}}

Explanation

Calcium level: Decreased due to furosemide, a loop diuretic that increases calcium excretion in the urine, leading to mild hypocalcemia.
Potassium level: Decreased due to furosemide, which causes potassium loss through diuresis. Lisinopril, an ACE inhibitor, can cause potassium retention, but in this case, the effect of furosemide dominates.
Sodium level: Decreased due to furosemide-induced diuresis, which can lead to hyponatremia by excessive sodium loss.
Edema: Improved due to furosemide, which promotes fluid removal and reduces volume overload associated with heart failure.
Oxygen saturation: Improved due to carvedilol, which reduces heart failure symptoms by decreasing myocardial oxygen demand and improving cardiac output.
Blood pressure: Lowered due to both carvedilol (a beta-blocker) and lisinopril (an ACE inhibitor), both of which reduce systemic vascular resistance.
Weight: Decreased due to both carvedilol, which helps manage fluid retention over time in heart failure, and furosemide, which directly reduces fluid overload through diuresis.

A. "You might experience swollen gums while taking this medication." B. "You can skip a dose of this medication if you are nauseated." C. "You can safely take this medication if you become pregnant." D. "You should expect to have blood work every 6 months while taking this medication."

Correct Answer is A

Explanation

A. "You might experience swollen gums while taking this medication." Phenytoin is known to cause gingival hyperplasia, which is swelling and overgrowth of the gums. This is a common side effect, and clients should be informed about it so they can maintain good oral hygiene and seek dental care if necessary.
B. "You can skip a dose of this medication if you are nauseated." Skipping doses is not advised. Phenytoin should be taken consistently, and skipping doses can lead to decreased seizure control. If nausea occurs, the client should contact their healthcare provider for guidance.
C. "You can safely take this medication if you become pregnant." Phenytoin is classified as a Category D medication, indicating evidence of risk to the fetus. Women of childbearing age should discuss effective contraception and consult their healthcare provider regarding the risks associated with taking phenytoin during pregnancy.
D. "You should expect to have blood work every 6 months while taking this medication." Regular monitoring of serum levels is necessary, typically every 1-3 months, especially after dosage changes. Monitoring ensures therapeutic levels and prevents toxicity, so stating that blood work is only required every 6 months may be insufficient.

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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

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A,C"},"C":{"answers":"C"},"D":{"answers":"C"},"E":{"answers":"B"},"F":{"answers":"A,B"},"G":{"answers":"B,C"}}

Explanation

A nurse is reinforcing teaching with a female client who is taking phenytoin. Which of the following statements should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is caring for a client who has been admitted to the mental health unit. While reinforcing teaching about the client's prescribed medications, the nurse communicates truthfully about the adverse effects of the medications. Which of the following ethical concepts is the nurse exhibiting?

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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?

A nurse is collecting data from a client who has heart failure and is taking furosemide. Which of the following findings should indicate to the nurse that the medication is effective?

A nurse is assisting in the care of an older adult client who was admitted from a long-term care facility. Exhibits Select the 3 findings that require immediate follow-up.

A nurse is assisting with the care of a client. Exhibits Select the 4 responsibilities the nurse has in relation to the client's advance directives.

A nurse is assisting in the care of a client on a labor and delivery unit. Exhibits Which of the following findings require further evaluation by the nurse? Select all that apply.

Exhibits

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