The practical nurse (PN) is assisting with preparation of a client for fecal diversion surgery. While inserting an indwelling urinary catheter, the client asks if the surgical opening will be visible. Which action should the PN implement?

Ask the client if he finished the bowel sterilization prescription.

Review the client's expectations of elimination after surgery.

Verify that the client had nothing by mouth (NPO) for the past 24 hours.

Determine if this is the first indwelling catheter the client has had.

Answer and Explanation

The Correct Answer is B

A.   Asking about the bowel sterilization prescription doesn't address the client's concern regarding the visibility of the surgical opening.
B.   Reviewing the client's expectations after surgery could address the client's query about the visibility of the surgical opening and offer information regarding elimination.
C.   Verifying the NPO status is important for surgery preparation but doesn’t directly address the client's specific concern.
D.   Determining if this is the first indwelling catheter doesn’t directly address the client's immediate concern regarding the surgical opening.

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Correct Answer is C

Explanation

A. Write an incident report about the bruises on the infant. - These areas might not be bruises; hence, writing an incident report without accurate information could be premature.
B. Review the labor and delivery record for birth trauma. - While important, it might not directly relate to the observed bluish-black areas.
C. Record the size and location of the areas in the infant's chart. - Documenting the observations is essential for tracking changes and informing other healthcare providers.
D. Notify the pediatrician of a possible bleeding problem with the infant. - Without further assessment, assuming a bleeding problem might be premature and unnecessarily alarming.

A. Assess her feelings about therapeutic abortions in the event the infant has been affected B. Identify current sexual partners so that they can be evaluated and treated for genital herpes if necessary. C. Instruct her to avoid sexual intercourse while active, visible lesions are present. D. Determine if the client has taken acyclovir for this outbreak of genital herpes.

Correct Answer is C

Explanation

A. Assess her feelings about therapeutic abortions in the event the infant has been affected. - While important to address concerns, the immediate priority is to manage the current outbreak and prevent transmission.
B. Identify current sexual partners so that they can be evaluated and treated for genital herpes if necessary. - Contact tracing is important but not the highest priority in managing the current outbreak.
C. Instruct her to avoid sexual intercourse while active, visible lesions are present. - This is crucial to prevent transmission of the herpes virus to the sexual partner and to reduce the risk of complications for the pregnancy.
D. Determine if the client has taken acyclovir for this outbreak of genital herpes. - While important for understanding the treatment history, instructing the client on preventive measures has a higher priority.

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The practical nurse (PN) is assisting with preparation of a client for fecal diversion surgery. While inserting an indwelling urinary catheter, the client asks if the surgical opening will be visible. Which action should the PN implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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