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.

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Correct Answer is A

Explanation

Choice A rationale:

The nurse should encourage the client to be assertive. Dependent Personality Disorder is characterized by a pervasive and excessive need to be taken care of, leading to submissive and clinging behavior. One of the treatment goals is to help the client develop assertiveness skills to reduce their dependence on others. Encouraging assertiveness allows the client to express their needs and make decisions for themselves, which is an essential aspect of their therapeutic journey toward independence.

Choice B rationale:

Assuming responsibility for making the client's decisions would not be appropriate. It would further reinforce the client's dependent behavior and hinder their progress towards independence. The goal of therapy is to promote autonomy and self-reliance, not to perpetuate dependency.

Choice C rationale:

Maintaining a verbal no-harm contract with the client may be necessary in some cases, especially if the client exhibits self-harming behaviors. However, it is not a primary teaching point when educating the caregiver about managing a client with Dependent Personality Disorder. The focus should primarily be on helping the client develop assertiveness and self-reliance.

Choice D rationale:

Limiting the client's social interactions is not an appropriate intervention. Social support can be beneficial for individuals with Dependent Personality Disorder, as it can help them build self-confidence and reduce their excessive reliance on one individual. Isolating the client would not be in their best interest.

A. "This medication will darken the color of my eyes.” B. "This medication will dilate my eyes.” C. "I should take a zinc supplement while taking this medication.” D. "I should check my heart rate while taking this medication.” cONTINUh.

Correct Answer is D

Explanation

Choice A rationale:

"This medication will darken the color of my eyes." This statement is not accurate. Timolol eye drops, which are commonly used to treat glaucoma, do not darken the color of the eyes. This statement indicates a misunderstanding of the medication's effects.

Choice B rationale:

"This medication will dilate my eyes." This statement is not accurate either. Timolol is a beta-blocker that works to reduce intraocular pressure by decreasing the production of aqueous humor in the eye. It does not dilate the eyes; in fact, it has the opposite effect.

Choice C rationale:

"I should take a zinc supplement while taking this medication." This statement is unrelated to the use of timolol eye drops for glaucoma and is not part of the standard treatment plan. There is no established connection between taking zinc supplements and using timolol for glaucoma management.

Choice D rationale:

"I should check my heart rate while taking this medication." This statement indicates an understanding of the teaching. Timolol is a beta-blocker that can lower heart rate and blood pressure. Clients using timolol eye drops should be advised to monitor their heart rate regularly and report any significant changes to their healthcare provider. This is important for safety and to ensure that the medication is not causing any adverse cardiovascular effects.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing discharge teaching with the caregiver of a client who has dependent personality disorder.Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who has primary open-angle glaucoma and a new prescription for timolol eye drops.Which of the following statements indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is collecting data from a client who is taking tranylcypromine and reports ingestion of tyramine-rich foods.The nurse should monitor the client for which of the following findings as an adverse effect of this medication?

A nurse is caring for a client who has peptic ulcer disease and is scheduled to undergo an esophagogastroduodenoscopy.Which of the following actions should the nurse take prior to the procedure?

A nurse is assisting with the care of a client who presents to the labor and delivery unit. Exhibits The nurse assisting with this client's care should expect which of the following prescriptions from the client's provider? Select all that apply.

A nurse is assisting with the care of a client on an orthopedic unit. Exhibits Select words from the choices below to fill in each blank in the following sentence. The client is at risk for developing dropdown.

The nurse is continuing to assist with the care of the client. Exhibits Select words from the choices below to fill in each blank in the following sentence. The complications that the client is at greatest risk for developing are dropdown and dropdown complications.

A nurse is assisting in the care of an older adult client who has COPD and is receiving albuterol treatments and 20 mg of prednisone twice daily.The client asks why the nurse is checking his blood glucose level.Which of the following responses should the nurse make?

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 admission of a client who has tuberculosis with a productive cough.Which type of isolation precautions should the nurse initiate for the client?