Difficulty: Medium
Average Score: 62%
Simulated
Passage / Scenario
NursesÔÇÖ NotesI&O
Postoperative Day 3
0900:
Client reports pain at surgical incision site as 5 on a scale of 0 to 10. Client reports bladder fullness. Perineal dressing Intact with minimal serosanguinous drainage. 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 as 8 on a scale of 0 to 10. Urinary catheter intact with 100 mL/hr of pink urine.
Select the 2 actions the nurse should prepare to take for the client.
Correct answer
C,E
Rationale
Fluid intake and sitz baths promote bowel function and comfort post-surgery.