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
The correct answer is Choice C.
Choice C rationale: Assessing the patient for orthostatic hypotension is crucial because patients who can only bear weight on one leg may have compromised balance and stability. Orthostatic hypotension, or a sudden drop in blood pressure upon standing, could lead to dizziness or fainting, increasing the risk of falls and injury. Identifying this condition before transferring the patient ensures appropriate interventions can be taken to maintain safety and prevent accidents. The nurse can then apply necessary precautions such as additional support or slow, gradual position changes to minimize the risk.
Choice A rationale: Rocking the patient up to a standing position might help initiate the transfer, but it’s not the immediate priority after securing a safe environment. Ensuring the patient's stability and monitoring their vital signs, especially for orthostatic hypotension, is essential before attempting any movement.
Choice B rationale: Pivoting on the foot that is the farthest from the chair is part of the transfer technique, but it should only be performed after confirming the patient is stable and not at risk of orthostatic hypotension. Proper assessment precedes this step to prevent potential falls.
Choice D rationale: Applying a gait belt to the patient is important for safe transfer, but again, this step follows the assessment of the patient's condition. The gait belt is an aid for the transfer process, but its effectiveness relies on the patient's ability to stand without becoming dizzy or faint.
Correct Answer is A
Explanation
Choice A rationale
Walking briskly is a weight-bearing exercise that is essential for maintaining bone mass, which can help to prevent osteoporosis. Regular weight-bearing exercise, such as a 20-30-minute aerobic exercise, 3 times a week, is recommended for older adults at risk for osteoporosis.
Choice B rationale
Riding a bicycle is a non-weight-bearing exercise. While it can contribute to overall fitness and health, it does not provide the same benefits for bone health as weight-bearing exercises like walking.
Choice C rationale
Performing isometric exercises can help to strengthen muscles, but these exercises do not have the same impact on bone health as weight-bearing exercises.
Choice D rationale
Engaging in high-impact aerobics can be beneficial for bone health, but it may not be suitable for an older adult at risk for osteoporosis due to the increased risk of injury.
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