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.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A.The prescription specifies “four times per day,” which is clear.

B.The medication specified is erythromycin, which is clear

C.The dosage of 500 mg is clearly specified.

D.The route of administration eg. oral, topical is not specified and needs to be clarified to ensure proper administration.

A. Limit the client's social interactions. B. Maintain a verbal no-harm contract with the client. C. Encourage the client to be assertive. D. Assume responsibility for making the client's decisions.

Correct Answer is C

Explanation

Dependent personality disorder is characterized by an excessive reliance on others for decision-making and a fear of being alone or taking responsibility. Encouraging the client to be assertive helps promote their independence and self-confidence. It allows them to express their needs and preferences, make decisions, and take responsibility for their own actions. Empowering the client to be assertive can enhance their overall well-being and promote healthier relationships.

Limiting the client's social interactions may exacerbate their dependency and hinder their progress in developing more self-reliance and independent coping skills. It is important to encourage appropriate and healthy social interactions while also promoting the client's independence.

Maintaining a verbal no-harm contract with the client is a strategy more commonly used for clients at risk of self-harm or harm to others. It may not be directly applicable to the care of a client with dependent personality disorder unless there are specific safety concerns. Assuming responsibility for making the client's decisions would reinforce their dependency and enable their avoidance of taking personal responsibility. It is important to promote autonomy and support the client in making their own decisions whenever possible.

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Naxlex Comprehensive Predictor Exams

A nurse is transcribing a client's prescription for erythromycin 500 mg four times per day. Which of the following information should the nurse clarify with the provider?

Correct Answer is D

Explanation

A nurse is reinforcing discharge teaching with the caregiver of a client who has dependent personality disorder. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

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