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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Free Nursing Study Resources

Correct Answer is A

Explanation

The correct answer is: a. The client’s date of birth.

Choice A reason: The client’s date of birth is a critical identifier in healthcare settings. It is unique to the individual and does not change, making it a reliable way to confirm a patient’s identity. This is especially important in acute care settings where accurate patient identification is crucial for safe medication administration. Using the date of birth along with another identifier, such as the patient’s name, aligns with the best practices for patient safety.

Choice B reason: While a client’s full medical diagnosis is important information for a nurse to know, it is not used as an identifier for medication administration. The diagnosis helps inform treatment decisions and care planning but does not uniquely identify a patient. Multiple patients could have the same diagnosis, which could lead to medication errors if used as an identifier.

Choice C reason: A client’s telephone number is not a standard identifier used in healthcare settings for medication administration. Telephone numbers can change and are not unique to an individual. They also do not provide immediate verification of a patient’s identity at the bedside.

Choice D reason: The room number of the client is not a primary identifier for patient identification in medication administration. Room numbers are not unique to individuals and can change if a patient is moved. It is possible for errors to occur if room numbers are used as the sole identifier, as another patient could be in that room at a different time.

A. A client who has a new diagnosis of diabetes mellitus and is awaiting teaching about meal planning. B. A client who has a urinary output of 30 mL in the past hour. C. A client who is postoperative following a hip arthroplasty and has a respiratory rate of 10/min. D. A client who is newly admitted and requires an admission assessment.

Correct Answer is B

Explanation

The correct answer is Choice B.

Choice A rationale: This client has a new diagnosis and requires initial teaching about meal planning, which is typically a responsibility of a registered nurse (RN) due to the need for specialized knowledge and teaching skills.

Choice B rationale: This client has a low urinary output, which needs to be monitored, but the care required is within the scope of practice of a licensed practical nurse (LPN). They can manage and report findings to the RN.

Choice C rationale: This client has a low respiratory rate postoperatively, which could indicate respiratory depression. This requires immediate assessment and intervention from an RN, who can make complex clinical judgments and initiate appropriate care.

Choice D rationale: This client needs an admission assessment, which includes comprehensive initial evaluation. An RN is required for this as it involves detailed assessment, care planning, and initiation of care.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute care setting is preparing to administer medications to a client. Which of the following information should the nurse obtain to identify the client?

Correct Answer is A

Explanation

A charge nurse is making assignments for a group of clients. Which of the following clients should the nurse assign to a licensed practical nurse?

Correct Answer is B

Explanation

A nurse is contributing to an in-service for newly licensed nurses about situations requiring an incident report. Which of the following examples should the nurse include?

A nurse is assisting with discharge planning for a client who is prescribed home oxygen at 1 to 2 L/min.The nurse should ensure that the client has which of the following supplies upon discharge?

A nurse is caring for an adolescent who states, "I failed my math exam because the teacher doesn't like athletes." The nurse should identify that the adolescent is using which of the following defense mechanisms?

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 providing care to a client who is immunocompromised.Which of the following should the nurse identify as a possible source of infection?

A nurse is contributing to the plan of care for a client who is pregnant and reports having trouble sleeping.Which of the following instructions should the nurse include in the plan of care?