Nurses' Notes Postoperative Day 3 0900:
The client reports pain at the surgical incision site as 5 on a scale of 0 to 10. The client reports bladder fullness. Perineal dressing intact with minimal serosanguinous drainage. The client transferred out of bed to a chair independently. Extremities cool and dry with 2+ peripheral pulses.
1300:
The client reports abdominal cramping and small, hard, painful bowel movements after lunch. Ambulating independently in the hallway. Reports pain as 8 on a scale of 0 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.
Irrigate the indwelling catheter with 500 mL of fluid.
Assist the client with a seat bath.
Encourage oral fluid intake.
Administer an enema.
Encourage prolonged dangling before ambulation.
Correct Answer : B,C
A. Not indicated and could lead to complications.
B. The client reports abdominal cramping and a small, hard, painful bowel movement. A sit bath can help provide relief and comfort to the perineal area, which can be beneficial after experiencing bowel discomfort.
C. The client reports pain and has had a small, hard, painful bowel movement. Encouraging oral fluid intake helps prevent dehydration and can soften the stool, making it easier to pass and reducing the risk of constipation.
D. Not necessary or appropriate without further assessment.
E. Not necessary and may not provide any additional benefit in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","F"]
Explanation
A. Oxygen saturation level: The client is restless, not following commands, and has labored respirations with crackles and wheezes in the breath sounds. Monitoring the oxygen saturation level is essential to assess the client's respiratory status and oxygenation.
B. Tremors: The client has tremors in their hands. Considering the client's history of Parkinson's disease, changes in tremors should be monitored and addressed promptly.
C. The immediate concern is addressing the respiratory distress.
D. Heart rate may also be monitored, but it's not as critical in this context.
E. Chronic health conditions are relevant for the overall care plan, but they do not require immediate intervention as compared to respiratory and tremor issues.
F. Respiratory rate: The client has labored respirations and abnormal breath sounds (crackles and wheezes). Monitoring the respiratory rate is important to evaluate the client's breathing pattern and respiratory distress.
Correct Answer is B
Explanation
A. Incorrect. Yellow crusts around the incision site are a normal part of healing after circumcision. Wiping them away can disrupt the healing process.
B. Correct. Applying pressure with gauze if bleeding occurs helps control bleeding and supports the healing process after circumcision.
C. Incorrect. A snug diaper might cause friction and discomfort for the healing circumcision site.
Diapers should be applied loosely to avoid rubbing against the area.
D. Incorrect. Applying antibiotic ointment is generally not recommended for circumcision care, especially after a Plausible circumcision. It can interfere with healing and increase the risk of infection.
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