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.

Encourage prolonged dangling before ambulation.

Irrigate indwelling catheter with 500 mL of fluid.

Administer an enema.

Assist the client with a sitz bath.

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.

Nursing Test Bank

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Correct Answer is A

Explanation

RSV is primarily transmitted through respiratory droplets when an infected person coughs or sneezes. To prevent the spread of RSV, it is important to implement droplet precautions. These precautions include wearing a mask and ensuring proper hand hygiene when in contact with the preschooler.

This helps minimize the risk of transmitting the virus to other individuals. Requesting an x-ray of the preschooler's neck is not indicated for RSV. RSV primarily affects the respiratory system, and an x-ray of the neck would not provide relevant information for the diagnosis or management of RSV.

Monitoring the preschooler's urine for protein is not specifically related to RSV. Proteinuria is not a typical manifestation or complication of RSV. Monitoring urine for protein is more relevant in conditions such as kidney disease or urinary tract infections.

Administering fluconazole to the preschooler is not indicated for RSV. Fluconazole is an antifungal medication used to treat fungal infections, and it would not be effective against a viral infection like RSV.

A. I should take a zinc supplement while taking this medication. B. This medication will darken the color of my eyes. C. 1 should check my heart rate while taking this medication. D. This medication will dilate my eyes.

Correct Answer is C

Explanation

Explanation

C.I should check my heart rate while taking the medication

Timolol is a medication commonly prescribed for the treatment of primary open-angle glaucoma, which is a chronic eye condition characterized by increased intraocular pressure

hacking the heart rate while taking timolol eye drops is important. Timolol belongs to a class of medications called beta-blockers, which can have systemic effects. These medications can enter the bloodstream and potentially affect heart rate and blood pressure. Monitoring the heart rate can help assess for any potential adverse effects of the medication.

Taking a zinc supplement in (option A) is not correct because it is not typically necessary while taking timolol eye drops. Zinc supplementation is not a direct requirement or related to the use of timolol for glaucoma treatment. The client should follow their healthcare provider's instructions regarding medication use and potential dietary modifications, but zinc supplementation is not specifically associated with timolol.

Timolol eye drops in (option B) is not correct because it does not darken the colour of the eyes. The purpose of timolol eye drops is to reduce intraocular pressure by decreasing the production of fluid in the eye. Eye colour changes are not known effects of timolol eye drops.

Timolol eye drops in (option D) is incorrect because it does not dilate the eyes. In fact, they work by reducing intraocular pressure, not by dilating the eyes. Eye dilation is typically achieved with the use of specific eye drops called mydriatics or with the use of specialized ophthalmic instruments during an eye examination.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a preschooler who has manifestations of respiratory syncytial virus. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who has primary open-angle glaucoma and a new prescription for timolol eye drops. Which of the following statements indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse on a medical-surgical unit is caring for a group of clients. Which of the following clients should the nurse see first?

A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following actions should the nurse take to promote progression toward independence and mobility for the client?

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 in an acute care facility is assisting with the development of an in-service about reducing environmental stressors to improve clients' sleep. Which of the following instructions should the nurse include?

A nurse is collecting data from a client who has thrombocytopenia. The nurse should identify that which of the following findings increases the client's risk for injury?

A nurse is reinforcing teaching with a client who has diabetes mellitus and is taking insulin lispro and insulin glargine. Which of the following instructions should the nurse include in the teaching?

A nurse is reinforcing teaching about breastfeeding with the mother of a full-term newbornwho is 5 days old. Which of the following statements by the mother indicates an understandingof the teaching?

A nurse is caring for a client who has bulimia nervosa. Which of the following actions should the nurse take first?