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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) I participate in physical activities 3 times per week: Engaging in physical activity is a positive behavior and is not considered high-risk. Regular physical activity is important for maintaining overall health and preventing obesity, cardiovascular disease, and other health issues.
B) I use sunscreen with an SPF of 10: While using sunscreen is a protective behavior, an SPF of 10 is lower than the recommended SPF of at least 30 for effective protection against harmful UV radiation. This is not the most significant high-risk behavior compared to others, but it still indicates some risk of sun damage.
C) I limit playing video games to 3 hours per day: Limiting screen time to 3 hours per day can be considered a balanced approach to video gaming. While excessive screen time can be problematic, 3 hours per day is not necessarily a high-risk behavior for an adolescent, as long as it doesn't interfere with other important aspects of life, like physical activity, sleep, and socialization.
D) I have had sexual relations, but did not get the HPV vaccine: Engaging in sexual activity without receiving the HPV vaccine is a high-risk behavior. The HPV vaccine helps prevent certain strains of the human papillomavirus, which can cause cervical cancer and other cancers. Lack of vaccination increases the risk of contracting HPV and developing related complications.
Correct Answer is A
Explanation
A) Encourage the client to use overbed trapeze:
Encouraging the client to use an overbed trapeze is an appropriate intervention to promote independence and mobility after an above-the-knee amputation. The trapeze allows the client to move, reposition themselves, and perform activities of daily living more independently, which is important for regaining strength and confidence during the rehabilitation process. It aids in improving upper body strength and assists in early mobility efforts.
B) Maintain abduction of the client's residual limb with a pillow:
Placing a pillow under the residual limb in a position that maintains abduction (separation of the residual limb away from the body) is not recommended after an above-the-knee amputation. This position can lead to contractures of the hip joint, limiting mobility and the ability to use a prosthetic limb in the future. Proper positioning usually involves keeping the residual limb flat or neutral to avoid deformities.
C) Caution the client to avoid a prone position while in bed:
This recommendation is incorrect. In fact, encouraging the client to spend time in the prone position (lying on their stomach) can help prevent hip contractures, especially after an above-the-knee amputation. It is important for the client to position their body in ways that encourage proper limb alignment and prevent long-term complications such as contractures that could impede mobility.
D) Keep a loose, absorbent dressing over the client's surgical site:
A loose, absorbent dressing is not ideal for post-surgical care following an amputation. A dressing should be secure, sterile, and changed regularly to prevent infection and promote optimal wound healing. Keeping a dressing loose could lead to the risk of infection or delayed healing. The nurse should follow the provider’s orders for dressing changes and monitor for signs of infection.
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