Difficulty: Medium
Average Score: 85%
Simulated
Passage / Scenario
Nurses' notesPostoperative day 2
0900:
Client reports history of deep vein thrombosis (DVT) after cholecystectomy 15 years ago.
Client reports pain of 5 on a scale of 0 to 10 at perineal surgical incision site and bladder fullness. Perineal dressing intact with minimal serosanguinous drainage.
Reports hard, painful bowel movement on postoperative day 1.
Client transferring out of bed to chair independently. Extremities cool and dry with 2+ peripheral pulses.
1300:
Client reports abdominal cramping and small, hard, painful bowel movement after lunch. Ambulating independently in hallway. Reports pain of 8 on a scale of 0 to 10 in perineum.
For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.
Correct answer
B,C,D
Rationale
[0, 1, 1]
The correct answer is B, C, D. Administering an enema to relieve constipation is appropriate postoperatively to prevent discomfort and complications. Irrigating an indwelling urinary catheter with 50 mL of normal saline helps maintain urinary catheter patency and prevent urinary tract infections. Placing a blanket roll under the client's knees while in bed helps prevent pressure ulcers. Applying warm compresses to the incision site may increase the risk of infection. Maintaining bed rest for 2 days postoperatively (E) may increase the risk of complications such as deep vein thrombosis.
The correct answer is B, C, D. Administering an enema to relieve constipation is appropriate postoperatively to prevent discomfort and complications. Irrigating an indwelling urinary catheter with 50 mL of normal saline helps maintain urinary catheter patency and prevent urinary tract infections. Placing a blanket roll under the client's knees while in bed helps prevent pressure ulcers. Applying warm compresses to the incision site may increase the risk of infection. Maintaining bed rest for 2 days postoperatively (E) may increase the risk of complications such as deep vein thrombosis.