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
Explanation
A. Correct. Leaving steris-trips on until they fall off naturally promotes wound healing and reduces the risk of infection.
B. Incorrect. A high-fat diet is not recommended post-cholecystectomy; a low-fat diet is usually advised to prevent discomfort.
C. Incorrect. Diarrhea is not a common or expected outcome following laparoscopic cholecystectomy.
D. Incorrect. While some postoperative nausea might be expected, it should not persist for several days. Prolonged nausea may require medical attention.
Correct Answer is C
Explanation
Since the client is prescribed home oxygen at 1 to 2 L/min, a nasal cannula is the most appropriate device for oxygen delivery in this scenario. A nasal cannula consists of two small prongs that are inserted into the client's nostrils, delivering oxygen directly into the nasal passages. It is a comfortable and commonly used device for low-flow oxygen therapy.
Petroleum jelly is not directly related to oxygen therapy and is not typically required for the use of a nasal cannula.
A reservoir bag is not typically used with a nasal cannula. It is a component of a different oxygen delivery system called a non-rebreather mask, which is used for high-flow oxygen therapy or in emergency situations.
An oxygen mask is also not typically used with a nasal cannula. It is a separate oxygen delivery device that covers the client's mouth and nose, delivering oxygen at a higher flow rate. Masks may be used in situations where higher concentrations or flows of oxygen are required, or when the client is unable to tolerate or use a nasal cannula effectively.
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