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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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

The correct answer is choicec. Assign the client to a negative-pressure airflow room.

Choice A rationale:

Administering aspirin to a client with varicella zoster is not recommended due to the risk of Reye’s syndrome, a serious condition that can cause swelling in the liver and brain.

Choice B rationale:

While contact precautions are important, varicella zoster also requires airborne precautions due to its highly contagious nature. This means that simply initiating contact precautions is not sufficient.

Choice C rationale:

Assigning the client to a negative-pressure airflow room is crucial because it helps contain the airborne virus and prevents it from spreading to other areas of the hospital.

Choice D rationale:

Having visitors remain at least 0.91 m (3 feet) away from the client is a good practice, but it is not sufficient on its own to prevent the spread of the virus. Airborne precautions, including a negative-pressure room, are necessary.

A. Instruct the client to take a brisk walk. B. Check the client's temperature. C. Provide the client with a glass of orange juice. D. Position the client on their left side.

Correct Answer is D

Explanation

A. Incorrect. Instructing the client to take a brisk walk might exacerbate their symptoms.
B. Incorrect. Checking the client's temperature is not indicated based on the reported symptoms.
C. Incorrect. Providing orange juice might help with low blood sugar but doesn't directly address the reported symptoms.
D. Correct. Positioning the client on their left side can improve blood flow to the heart and uterus, alleviating symptoms of dizziness and racing heart that can occur due to pressure on the vena cava when lying flat on the back.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?

Correct Answer is C

Explanation

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?

Correct Answer is D

Explanation

A nurse in an acute care setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include?

A nurse is caring for a client who is 12 hr postpartum and has deep vein thrombosis of the left leg. The client is receiving anticoagulant therapy. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a client who is postoperative following a laparoscopic cholecystectomy. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?

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 caring for an adult client who reports having trouble getting to sleep at night. Which of the following recommendations should the nurse make?

A nurse is assisting with the care of an adolescent. Exhibits Select 1 condition and 1 finding to fill in each blank in the following sentence. The adolescent is at risk for developing dropdown as evidenced by dropdown

A nurse is reinforcing teaching with a client who is postpartum about the measles, mumps, and rubella (MMR) vaccine. Which of the following instructions should the nurse include in the teaching?