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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
Explanation
Rationale for Correct Choices:
- N95 respirator. The client’s presentation of a cough, fatigue, night sweats, weight loss, and positive sputum culture for M. tuberculosis strongly suggests active tuberculosis (TB). Tuberculosis is transmitted through airborne particles, and an N95 respirator is required to protect healthcare workers from inhaling these particles. The N95 mask is specifically designed to filter out small particles, including the Mycobacterium tuberculosis bacteria.
- Gloves. Gloves should be worn when caring for patients with suspected or confirmed TB to prevent contact transmission. While TB is primarily transmitted via airborne particles, gloves are still necessary to protect healthcare workers from coming into contact with bodily fluids such as sputum or any other potentially contaminated materials.
Rationale for Incorrect Options:
- Face shield. A face shield is not required as primary protection for TB. While face shields can protect against splashes and droplets, TB is primarily transmitted via airborne particles, for which an N95 respirator is more appropriate.
- Surgical mask. A surgical mask is not sufficient for protecting healthcare workers against tuberculosis because it does not filter out small airborne particles like the N95 respirator does. Surgical masks are primarily intended for droplet precautions, but tuberculosis is spread through airborne transmission, necessitating an N95 mask for adequate protection.
- Gown. A gown is not required in this situation unless the patient has other symptoms or conditions that increase the risk of contamination, such as excessive wound drainage or the potential for body fluid splashes. For TB transmission, the primary concern is airborne transmission, and appropriate PPE focuses on respiratory protection (N95) and gloves for contact precautions.
Correct Answer is B
Explanation
A. Apply a warm pack to the client's puncture site. Applying a warm pack to the puncture site is not appropriate immediately following cerebral angiography. Cold compresses are generally recommended initially to reduce swelling and discomfort, while warmth may be used later as advised by the healthcare provider.
B. Monitor for bleeding at the catheter site. Monitoring for bleeding at the catheter site is a critical action after cerebral angiography. The nurse should assess the site frequently for signs of hematoma or excessive bleeding, which can indicate complications from the procedure.
C. Replace the client's pressure dressing in 2 hr. The pressure dressing should not be replaced without specific orders from the healthcare provider. The nurse should assess the dressing for any signs of bleeding or drainage and follow the protocol for dressing changes as indicated.
D. Encourage the client to ambulate in 1 hr. Early ambulation may not be safe immediately after cerebral angiography, especially if the client has undergone a procedure involving sedation or if there is a risk of complications. The nurse should follow the provider's orders regarding activity restrictions and assess the client's readiness for ambulation based on their condition and vital signs.
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