Select the 2 actions the nurse should prepare to take for the client.

Encourage prolonged dangling before ambulation.

Administer an enema.

Encourage oral fluid intake.

Irrigate indwelling catheter with 500 mL of fluid.

Assist the client with a sitz bath.

Answer and Explanation

Correct Answer : C,E

A. Encourage prolonged dangling before ambulation.
Prolonged dangling is not necessary for this client, who is already ambulating independently. Extended dangling may increase the risk of orthostatic hypotension without providing significant benefits.

B. Administer an enema.
An enema is not the first-line intervention for postoperative constipation. The client has had a bowel movement, albeit small and painful, so increasing fluids and noninvasive measures like a sitz bath should be attempted first.

C. Encourage oral fluid intake.
Adequate hydration helps soften stool and prevent constipation, a common postoperative concern. The client’s fluid intake should be increased to support bowel function and improve urinary output.

D. Irrigate indwelling catheter with 500 mL of fluid.
The client has pink urine but is maintaining an adequate output of 100 mL/hr. Routine catheter irrigation is unnecessary unless there is evidence of obstruction, such as decreased urine flow or clot formation.

E. Assist the client with a sitz bath.
A sitz bath can provide comfort by promoting relaxation of perineal muscles, reducing pain during bowel movements, and improving circulation to the surgical site, which may aid healing.

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Correct Answer is B

Explanation

A) Completely undress the toddler:
Completely undressing a toddler can cause unnecessary distress and anxiety, especially if they are not prepared for the examination. It’s more appropriate to undress the toddler only as needed for the physical exam and allow them to remain clothed or partially clothed whenever possible to help them feel secure.

B) Allow the toddler to handle the equipment:
Allowing a toddler to handle the medical equipment is an excellent way to reduce fear and anxiety. This familiarizes the child with the instruments and allows them to feel more in control of the situation. It also helps in building trust with the nurse, making the examination less intimidating for the toddler.

C) Start the examination with routine immunizations:
Immunizations can be particularly stressful for toddlers, so starting the examination with vaccines is not the best approach. It’s better to begin with non-invasive procedures, such as listening to the heart or measuring the toddler’s height and weight, to build rapport before proceeding to any painful procedures.

D) Thoroughly explain each procedure to the toddler:
While it’s important to explain the examination to the toddler in simple, age-appropriate language, toddlers typically have a limited understanding of detailed explanations. Over-explaining may increase anxiety. Instead, it's better to keep things brief and comforting, using simple phrases, and focus on creating a positive experience.

A. Temporary memory loss B. Voice alteration C. Tingling of the scalp D. Neck pain

Correct Answer is A

Explanation

A) Temporary memory loss: Temporary memory loss is a well-known and common side effect following electroconvulsive therapy (ECT). Clients may experience short-term memory issues, such as forgetting events that occurred around the time of the procedure or difficulties recalling information. This side effect is usually temporary and tends to resolve as the brain recovers from the procedure.

B) Voice alteration: Voice alteration is not a typical side effect of electroconvulsive therapy. ECT primarily affects brain function, particularly memory and cognitive processes, and does not have a direct effect on the voice or vocal cords.

C) Tingling of the scalp: Tingling of the scalp is not a common adverse reaction to
electroconvulsive therapy. While there may be some minor physical sensations or discomfort during the procedure, tingling is not a typical side effect associated with ECT.

D) Neck pain: Neck pain is not a usual adverse reaction of electroconvulsive therapy. Some discomfort might occur after the procedure due to muscle tension or the positioning during the therapy, but it is not a common or prominent side effect like memory loss.

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Body system	Findings
Head. Eyes. Ears. Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Weight gain
Hematologic	Increased bruising Increased bleeding tendancies Insomnia
Genitourinary	Darkening of the urine Urinary frequency

Select the 2 actions the nurse should prepare to take for the client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a toddler during a well-child visit. Which of the following actions should the nurse take to prepare the toddler for physical examination?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client who is about to undergo electroconvulsive therapy. The nurse should explain to the client that which of the following adverse reactions can occur following the procedure?

Correct Answer is A

Explanation

A nurse is reviewing the medical record for a child who is scheduled to receive a varicella immunization. Which of the following findings in the client's record should the nurse recognize as a contraindication?

A nurse is reinforcing teaching with a female client who is taking phenytoin. Which of the following statements should the nurse include in the teaching?

A nurse at an outpatient clinic receives a call from a client who reports experiencing syncope after starting a new prescription for enalapril. Which of the following instructions should the nurse give the client?

A nurse is assisting with the evaluation of a facility's safety plan. Which of the following indicates that the safety plan is effective?

A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?

A nurse is reinforcing teaching with a client who has a new prescription for enoxaparin. The nurse should identify which of the following over-the-counter products as unsafe for use with enoxaparin.

A nurse is reinforcing teaching with a client who has cancer and is undergoing external radiation therapy. Which of the following instructions should the nurse include in the teaching?