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    ATI LPN Comprehensive Predictor 2023 Proctored Exam 3
    Select All That Apply

    Nurses' Notes Postoperative Day 3 0900: The client reports pain at the surgical incision site as 5 on a scale of 0 to 10. The client reports bladder fullness. Perineal dressing intact with minimal serosanguinous drainage. The client transferred out of bed to a chair independently. Extremities cool and dry with 2+ peripheral pulses. 1300: The client reports abdominal cramping and small, hard, painful bowel movements after lunch. Ambulating independently in the 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.

    Explanation & Rationale

    A. Not indicated and could lead to complications. B. The client reports abdominal cramping and a small, hard, painful bowel movement. A sit bath can help provide relief and comfort to the perineal area, which can be beneficial after experiencing bowel discomfort. C. The client reports pain and has had a small, hard, painful bowel movement. Encouraging oral fluid intake helps prevent dehydration and can soften the stool, making it easier to pass and reducing the risk of constipation. D. Not necessary or appropriate without further assessment. E. Not necessary and may not provide any additional benefit in this context.

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