A client in the emergency department reports abdominal pain and has not had a bowel movement for the past 7 days. Based on the client’s clinical findings, which action should the nurse take?
Assist the client to a left side-lying position with the right knee flexed.
Prepare the client for a chest x-ray.
Administer a cleansing enema.
Auscultate the client’s bowel sounds.
The Correct Answer is C
Choice A rationale
Assisting the client to a left side-lying position with the right knee flexed is a common position for administering an enema. However, this action alone would not address the client’s immediate need for relief from constipation.
Choice B rationale
Preparing the client for a chest x-ray would not be the most appropriate action based on the client’s symptoms. The client is experiencing abdominal pain and constipation, which are not typically associated with conditions that would require a chest x-ray.
Choice C rationale
Administering a cleansing enema is the correct action. The client has not had a bowel movement for the past 7 days and reports abdominal pain. These symptoms, along with the findings from the abdominal x-ray, suggest that the client is experiencing constipation. A
cleansing enema can help to relieve constipation by stimulating bowel movements and removing impacted fecal matter.
Choice D rationale
Auscultating the client’s bowel sounds is an important part of assessing the client’s gastrointestinal status. However, given the client’s symptoms and the results of the abdominal x-ray, administering a cleansing enema would be the most appropriate action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Tuberculosis is a serious infectious disease that affects the lungs. However, it does not typically cause lung hyperinflation.
Choice B rationale
Bronchitis is an inflammation of the bronchial tubes. While it can cause symptoms similar to those described, it does not typically cause lung hyperinflation or localized pneumonia in the left upper lobe.
Choice C rationale
Pneumonia is an infection that inflames the air sacs in one or both lungs. The client’s symptoms of a productive cough with thick yellow sputum, crackles in the left upper lobe, and decreased breath sounds at bases bilaterally are consistent with pneumonia. The chest x-ray showing left upper lobe pneumonia confirms this diagnosis.
Choice D rationale
Asthma is a condition in which a person’s airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe. While asthma can cause lung hyperinflation, it does not typically cause localized pneumonia in the left upper lobe.
Correct Answer is B
Explanation
Choice A rationale
Inserting the suction catheter while the patient is swallowing is not the recommended technique for nasotracheal suctioning. This could cause discomfort and potentially lead to aspiration.
Choice B rationale
Applying intermittent suction when withdrawing the catheter is the correct technique for nasotracheal suctioning. This helps to remove secretions effectively while minimizing trauma to the nasal and tracheal mucosa.
Choice C rationale
Placing the catheter in a location that is clean and dry for later use is not a recommended practice. After suctioning, the catheter should be properly cleaned or disposed of to prevent infection.
Choice D rationale
Holding the suction catheter with their clean, non-dominant hand is not a recommended practice. The nurse should use clean gloves and proper hand hygiene when performing nasotracheal suctioning to prevent infection.
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