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 C

Explanation

A) Dampened clothes are used for dusting the area: Using dampened clothes for dusting can help minimize the spread of dust and particulate matter in the environment. As long as the cloth is clean and properly disinfected, this action is not typically a source of infection. This is generally a safer approach for cleaning and does not pose an immediate infection risk.

B) Waste containers are lined with: While the phrasing is incomplete, if waste containers are lined properly with appropriate liners and are disposed of regularly, they should not serve as a significant source of infection. Waste disposal is important, but a properly lined container reduces the risk of contamination.

C) Soiled linens are placed on the floor: Placing soiled linens on the floor is a significant source of potential infection for immunocompromised clients. Floors can harbor bacteria, viruses, and other pathogens, and placing soiled linens there increases the likelihood of cross-contamination. The linens should be handled in a way that prevents contact with unclean surfaces to avoid spreading infection.

D) Uncapped sharps are put in a puncture-resistant container: A puncture-resistant container is designed to safely contain sharps such as needles, scalpels, or other sharp objects, minimizing the risk of injury. If sharps are uncapped, however, they could present a risk of needle-stick injury or contamination. However, the main risk comes from improper disposal, not the container itself. Proper disposal in an appropriately designed container is essential to minimizing infection risks.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C","dropdown-group-3":"C"}

Explanation

The nurse anticipates the client will likely require blood transfusion as evidenced by the client’s low hemoglobin and low hematocrit.

Rationale:

(i)

B. Blood transfusion: The client’s hemoglobin (9.1 g/dL) and hematocrit (27%) are significantly low, suggesting anemia due to gastrointestinal blood loss. A blood transfusion may be necessary to restore adequate oxygen-carrying capacity and prevent further hemodynamic instability.

(ii)

C. Low hemoglobin: A hemoglobin level below normal indicates blood loss, likely from a bleeding peptic ulcer. This finding supports the need for intervention to prevent further complications such as hypoxia or shock.

F. Low hematocrit: A low hematocrit confirms anemia and blood volume depletion. This finding, along with the client's symptoms and history of dark, tarry stools, further supports the need for a blood transfusion.

Incorrect:

(i)

A. Proton pump inhibitor therapy: While PPIs are essential for ulcer management, they do not immediately address acute blood loss

C. Antibiotic therapy: Antibiotics are needed to eradicate H. pylori, but they are not the primary intervention for anemia.

D. Surgical intervention: Surgery is considered only if bleeding is severe and refractory to medical management.

E. Intravenous fluid resuscitation: IV fluids can help stabilize blood pressure but do not directly correct anemia.

(ii)

A. Elevated white blood cell count: The client’s WBC count is normal, making it irrelevant to this scenario.

B. Positive H. pylori test: While H. pylori is the likely cause of the ulcer, this result does not directly indicate the need for a blood transfusion.

D. Epigastric tenderness: This is a symptom of peptic ulcer disease but does not directly relate to the need for a blood transfusion.

E. Dark, tarry stools: While indicative of gastrointestinal bleeding, the direct lab evidence of anemia (low hemoglobin and hematocrit) is more critical in determining the need for transfusion.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care to a client who is immunocompromised. Which of the following should the nurse identify as possible source of infection?

Correct Answer is C

Explanation

A nurse is assisting with the care of a client who is admitted to the medical surgical unit. Complete the following sentences by using the list of options: The nurse anticipates the client will likely require ______ as evidenced by the client’s _______ and ______.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C","dropdown-group-3":"C"}

Explanation

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