Nurses' Notes.
Postoperative Day 3. 0900: Client reports pain at surgical incision site as 5 on a scale of 0 to. 10. Client reports bladder fullness.
Perineal dressing intact with minimal serosanguinous drainage.
Client transferring out of bed to chair independently.
Extremities cool and dry with 2+. peripheral pulses.
1300: Client reports abdominal cramping and small, hard, painful bowel movement after lunch.
Ambulating independently in. hallway.
Reports pain as 8 on a scale ofO to 10. Urinary catheter intact with 100 mL/hr of pink urine.
Select the 2 actions the nurse should prepare to take for the client.
Administer an enema.
Assist the client with a sitz bath.
Irrigate indwelling catheter with 500 mL of fluid.
Encourage prolonged dangling before ambulation.
Encourage oral fluid intake.
Correct Answer : A,E
Choice A rationale:
Administering an enema can help relieve the client’s abdominal cramping and small, hard, painful bowel movement. An enema is a procedure that involves introducing a liquid solution into the rectum to promote evacuation of feces. It can be used to relieve constipation, which seems to be the client’s issue based on the description of their bowel movement.
Choice B rationale:
Assisting the client with a sitz bath may not be necessary at this time. A sitz bath is typically used to soothe and cleanse the perineal area, particularly after childbirth or surgery. While the client does have a surgical incision, the notes indicate that the perineal dressing is intact with minimal serosanguinous drainage, suggesting that the incision site is not currently problematic.
Choice C rationale:
Irrigating an indwelling catheter with 500 mL of fluid is not recommended unless there is a specific indication, such as the catheter being blocked. The client’s urinary catheter is intact with 100 mL/hr of pink urine, which suggests that it is functioning properly.
Choice D rationale:
Encouraging prolonged dangling before ambulation may not be beneficial for this client. Dangling involves sitting on the edge of the bed with legs hanging down before standing up. This can help prevent dizziness upon standing. However, the notes indicate that the client is already ambulating independently in the hallway, suggesting that they do not have issues with mobility or dizziness.
Choice E rationale:
Encouraging oral fluid intake can help alleviate constipation by softening stools and promoting bowel movements. It can also help maintain hydration, which is particularly important for postoperative clients. Therefore, this would be a beneficial action for the nurse to take for this client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Positioning the client supine with legs elevated is not an appropriate intervention for a client with ascites due to cirrhosis. It may help with other conditions, but in ascites, it can increase pressure on the abdomen and worsen fluid accumulation.
Choice C rationale:
Restricting the client's sodium intake to 3g per day is a valid intervention for a client with ascites due to cirrhosis. However, measuring the abdominal girth daily is a more immediate and actionable intervention to monitor the progression of ascites and adjust treatment accordingly.
Choice D rationale:
Keeping the client's daily protein intake below 0.8 g/kg is not the standard practice for managing ascites in cirrhosis. In fact, adequate protein intake is important to prevent malnutrition in these clients, so protein restriction is not recommended unless specifically indicated by a healthcare provider.
Correct Answer is C
Explanation
Choice A rationale:
Carrying the baby to the nursery may not align with facility security measures. Typically, hospitals have strict protocols for baby transport within the facility, including the use of identification bands.
Choice B rationale:
Taking the baby to the lobby to visit family may also not be in line with security measures. Visitors should typically come to the designated patient areas rather than taking the baby to the lobby.
Choice C rationale:
Having an identification band that matches the one the baby wears is the correct understanding of facility security measures. This ensures proper identification of the baby and helps prevent infant abduction or mix-ups.
Choice D rationale:
Removing the security band to give it to a family member is not in line with security measures. The baby's identification band should remain intact at all times to ensure proper identification and security.
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