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.

Answer and Explanation

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

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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.

A. Check on the client every 10 min during the bath. B. Add bath oil to the water after the client gets into the tub. C. Drain the tub water before the client gets out. D. Allow the client to remain in the bath for 30 min.

Correct Answer is C

Explanation

Answer is:Drain the tub water before the client gets out.

Explanation: This is the correct answer because it reduces the risk of slipping and falling for the client, especially if they have limited mobility or balance problems. The other options are incorrect because:

Checking on the client every 10 min during the bath is not enough to ensure their safety and comfort.The nurse should check on them more frequently, such as every 5 to 10 minutes, depending on their needs and preferences.
Adding bath oil to the water after the client gets into the tub is not a good idea because it can make the water slippery and increase the risk of falling.The nurse should add bath oil to the water before the client gets into the tub, or use a non-slip mat or shower chair.
Allowing the client to remain in the bath for 30 min is too long and can cause dehydration, hypothermia, or skin irritation.The nurse should instruct the client to remain in the tub for no longer than 20 min, unless otherwise ordered by a physician.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about circumcision care with the parent of an infant who just underwent a Plausible circumcision. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is assisting a client who requests to take a tub bath. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client about the use of budesonide for asthma management. Which of the following statements by the adolescent indicates an understanding of the teaching?

A nurse is reinforcing teaching about newborn care with a new guardian. Which of the following statements by the guardian indicates an understanding of the teaching?

A nurse is collecting data from a client who reports feeling stress. Which of the following should the nurse identify as an external stressor?

A nurse is collecting data from a client during a routine prenatal visit. The client is in their second trimester of pregnancy and reports feeling dizzy, has a racing heart, and becomes pale while lying on their back. Which of the following actions should the nurse take?

A nurse is helping to place a client into the prone position. The nurse should use a small pillow to relieve pressure from which of the following areas of the client's body?

A nurse is reinforcing teaching with a client who has a new prescription for enoxaparin. The nurse should identify which of the following over-the-counter products as unsafe for use with enoxaparin.

A nurse is reviewing the medical records of five clients. For which of the following events should the nurse write an incident report? (Select all that apply.)