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 B

Explanation

A. Administer granulocyte colony-stimulating factor. This medication stimulates neutrophil production in clients with severe neutropenia, such as those undergoing chemotherapy. While HIV can cause neutropenia, routine administration is not necessary unless the infant has recurrent infections and significantly low neutrophil counts.
B. Monitor the infant's lymphocyte count. CD4+ T-cell levels are key indicators of immune function in infants with HIV. Since HIV targets these cells, regular monitoring helps assess disease progression and the effectiveness of antiretroviral therapy, guiding treatment adjustments when needed.
C. Educate the infant's guardians about exchange transfusions. Exchange transfusions are used for conditions like severe neonatal hyperbilirubinemia or sickle cell disease, not HIV. Managing HIV in infants focuses on early antiretroviral therapy, routine lab monitoring, and infection prevention.
D. Initiate droplet precautions. Standard precautions, such as hand hygiene and appropriate use of personal protective equipment, are sufficient for infection control. HIV is not transmitted through respiratory droplets but through direct contact with infected blood, breast milk, or other bodily fluids.

A. "Discontinue this medication if this occurs again." B. "Sit back down for a few minutes when this occurs." C. "Restrict your daily fluid intake." D. "Take a daily potassium supplement."

Correct Answer is B

Explanation

A. Discontinue this medication if this occurs again. Stopping a newly prescribed medication without consulting a provider is not recommended. Many medications, including antihypertensives, can cause lightheadedness, and adjustments or precautions should be discussed with a healthcare provider rather than discontinuing the drug independently.
B. Sit back down for a few minutes when this occurs. Lightheadedness upon standing is often due to orthostatic hypotension, which can be managed by sitting back down to allow blood pressure to stabilize. Slowly changing positions, staying hydrated, and rising gradually can also help minimize symptoms.
C. Restrict your daily fluid intake. Reducing fluid intake can worsen symptoms of orthostatic hypotension by decreasing blood volume, leading to further drops in blood pressure. Instead, maintaining adequate hydration is essential to support circulatory stability and prevent dizziness.
D. Take a daily potassium supplement. Unless there is a confirmed potassium deficiency, supplementation is unnecessary and could lead to hyperkalemia, especially if the client is on medications affecting potassium levels. Lightheadedness is more commonly related to blood pressure changes rather than potassium imbalances.

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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 assisting with the plan of care for a 10-month-old infant who has HIV. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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Exhibits

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