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.

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Choice A rationale:

Instructing parents to avoid bringing fresh flowers into the room is not the primary intervention for a child with Clostridium difficile. While it is essential to maintain a clean environment, the most critical action is to implement proper infection control measures.

Choice B rationale:

This is the correct answer. Initiating contact precautions is crucial when caring for a child with Clostridium difficile. This includes using gloves and gowns to prevent the spread of the bacteria to others.

Choice C rationale:

Using a HEPA filtration system in the room is not the first-line intervention for managing Clostridium difficile. While it can help maintain air quality, it does not directly address the transmission of the bacteria.

Choice D rationale:

Using an N95 respirator is not the primary action in caring for a child with Clostridium difficile. Contact precautions, such as gloves and gowns, are more critical to prevent the spread of infection.

A. Vitamin D. B. Protein. C. Calcium. D. Fats.

Correct Answer is B

Explanation

Choice A rationale:

While vitamin D is essential for bone health and wound healing, it is not the primary nutrient to focus on in this case. Protein plays a crucial role in wound healing because it is necessary for tissue repair and the production of collagen, which is essential for wound closure.

Choice B rationale:

Increasing protein intake is the correct choice. Proteins are the building blocks of tissue repair and wound healing. Adequate protein intake is essential for promoting the healing of open wounds.

Choice C rationale:

Calcium is important for bone health but is not the primary nutrient to address in this situation. Calcium is not directly involved in wound healing processes.

Choice D rationale:

Fats are necessary for overall health, but they do not have a direct role in wound healing. Protein intake is more critical in this context to promote tissue repair and healing.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 2-year-old child who has Clostridium difficile.Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client who has an open leg wound and is experiencing difficulty healing.The nurse should encourage the client to increase which of the following nutrients in his diet?

Correct Answer is B

Explanation

A nurse is providing a client with IV fluids and finds that the IV pump screen is malfunctioning.Which of the following actions should the nurse take?

A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis.Which of the following interventions should the nurse recommend to include in the plan?

A nurse is assisting the provider with a lumbar puncture for a client who has manifestations of meningitis.Into which of the following positions should the nurse assist the client?

A nurse is reinforcing teaching with a client who has genital herpes.Which of the following information should the nurse include in the teaching?

A nurse is reinforcing teaching with a client who has a new prescription for a cervical cap as a form of contraception.Which of the following statements by the client indicates an understanding of the teaching?

A nurse is reinforcing dietary teaching with a client whose prepregnancy BMI was 30.5. The nurse should include that which of the following is an acceptable weight gain for this client?

A nurse is assisting with the care of a client who is in the latent stage of labor and has pelvic pain with contractions.Which of the following actions should the nurse take?

A nurse is assisting with the discharge of an older adult client who has early onset dementia and lives with their adult child who works full time.Which of the following resources should the nurse recommend to the family to assist with the client's care?