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Read the information below.

  • 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.
  • Client reports abdominal cramping and small, hard, painful bowel movement after lunch.
  • Ambulating independently in hallway.
  • Reports pain as 8 on a scale of 0 to 10, Urinary catheter intact with 100 mL/hr of pink urine.

A.

Encourage prolonged dangling before ambulation.

B.

Irrigate indwelling catheter with 500 mL of fluid.

C.

Administer an enema.

D.

Assist the client with a sitz bath.

E.

Encourage oral fluid intake.

Answer and Explanation

The Correct Answer is E

Adequate fluid intake helps to soften the stool, prevent constipation, and ease bowel movements. It can also help with bladder function and prevent urinary tract infections. This intervention is particularly relevant given the client's complaint of abdominal cramping and a small, hard, painful bowel movement.

The other options are not appropriate based on the information provided:

  • "Encourage prolonged dangling before ambulation" is not necessary or relevant in this case. The client is already transferring out of bed to a chair independently and ambulating independently in the hallway, indicating sufficient mobility.
  • "Irrigate indwelling catheter with 500 mL of fluid" is not indicated based on the provided information. The urinary catheter is intact, and the client is producing an appropriate amount of urine. There is no indication of urinary retention or need for irrigation.
  • "Administer an enema" is not necessary at this point. The client has reported a small, hard, painful bowel movement, which indicates constipation. However, conservative measures such as encouraging oral fluid intake and possibly adding dietary fiber should be tried first before considering an enema.
  • "Assist the client with a sitz bath" is not directly related to the client's current symptoms. A sitz bath is typically used for perineal hygiene, pain relief, or healing after certain surgical procedures, but it does not address the reported abdominal cramping or constipation.


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Related Questions

Correct Answer is ["A","B","C","E","G"]

Explanation

Based on the given information, the nurse should take the following actions in preparation for surgery:

  • Obtain a complete blood count: This is important to assess the client's hemoglobin, hematocrit, and other blood parameters before surgery.
  • Prepare the client for insertion of an 18-gauge peripheral IV prior to surgery: Adequate IV access is necessary for the administration of fluids and medications during and after surgery.
  • Administer Rh, D immune globulin prior to surgery: This action is indicated if the client is Rh-negative and there is a possibility of fetal-maternal blood mixing during the termination of pregnancy. Rh, D immune globulin is given to prevent sensitization to Rh-positive blood.
  • Verify consent form is signed by the client: Ensuring that the client has provided informed consent is essential before proceeding with any surgical intervention.
  • Remind the client to be NPO (nothing by mouth) prior to surgery: It is important for the client to have an empty stomach to reduce the risk of aspiration during anesthesia.

The following actions are not indicated based on the given information:

  • Explaining the surgical procedure to the client: Although it is important for the client to have an understanding of the procedure, this is typically done by the surgeon rather than the nurse.
  • Assisting with administration of AB positive blood products if needed: There is no indication of the need for blood products based on the information provided. Blood product administration would be determined based on the client's specific condition and surgical requirements.

Correct Answer is A

Explanation

This statement reflects an important recommendation for car seat safety. It is recommended to keep infants and toddlers rear-facing in their car seats until they reach the age of 2 or until they outgrow the height and weight limits specified by the car seat manufacturer. Rear-facing car seats provide better protection for the child's head, neck, and spine in the event of a crash. "I should position the car seat's retainer clip at the level of my baby's belly button." The correct position for the retainer clip is at armpit level. It should be positioned across the chest, resting on the bony part of the child's shoulders. Placing the retainer clip at the level of the belly button can be unsafe and may not provide proper protection.

"I should enable the airbag when my baby is in the front seat of the car." It is not recommended to place a rear-facing car seat in the front seat of a vehicle with an active airbag. The force of the airbag deployment can cause serious injuries to the child. The safest place for a rear-facing car seat is in the back seat of the vehicle.

"I should place my baby in the car seat at a 90-degree angle." The angle at which the car seat is installed depends on the specific instructions provided by the car seat manufacturer. It is important to follow the manufacturer's guidelines for proper installation. Some car seats have built-in angle indicators or adjustable recline positions to help achieve the correct angle for optimal safety.

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