A client on a mechanical soft diet is experiencing constipation and asks the nurse for a glass of prune juice. After auscultating decreased bowel sounds, which action should the nurse implement?

Restrict oral fluid intake.

Offer to warm the prune juice.

Advance to a regular diet.

Initiate bowel training protocol.

Answer and Explanation

The Correct Answer is D

A. Restrict oral fluid intake is not appropriate in this situation. Decreased bowel sounds and constipation may indicate a need for hydration, not restriction of fluids. Fluids are essential to help prevent and alleviate constipation.

B. Offer to warm the prune juice may be helpful in some cases to encourage the client to drink, but it does not address the underlying issue of constipation and decreased bowel sounds. A more comprehensive intervention, such as bowel training, is needed.

C. Advance to a regular diet may not be appropriate without assessing the client's tolerance for additional food types. The client is on a mechanical soft diet, which may already be sufficient. Advancing to a regular diet could potentially exacerbate the constipation.

D. Initiate bowel training protocol is the most appropriate action. Bowel training is designed to help manage constipation and promote regular bowel movements. This may include dietary adjustments, increased fluid intake, and other measures such as scheduled toileting.

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Correct Answer is ["D","E"]

Explanation

A. Notify the client's next of kin prior to surgery is not appropriate unless the client provides explicit consent. The nurse must respect the client's autonomy and confidentiality.

B. Encourage the client to execute a will that identifies a guardian for her children is outside the nurse's role. While the client’s family arrangements are important, this is not directly relevant to the surgical admission process.

C. Flag the client's record with "do not resuscitate" is not appropriate unless the client has completed the necessary documentation, such as an advance directive or physician orders for life-sustaining treatment (POLST).

D. Document the client's statement on the admission form is essential to ensure the healthcare team is aware of the client’s expressed wishes.

E. Explain the benefit of executing an advanced directive is appropriate because it informs the client about formalizing their wishes to avoid potential confusion during medical care.

A. Avoid naps B. Eat a heavy meal before bed C. Watch television in bed to fall asleep D. Exercise in the evening E. Try to go to bed and awaken at the same time every day F. Avoid alcohol in the evening G. Take an analgesic before bed

Correct Answer is ["A","E","F"]

Explanation

A. Avoid naps – Napping during the day, especially late in the afternoon or evening, can interfere with the ability to fall asleep at night. It is generally recommended to avoid naps if experiencing insomnia.

B. Eat a heavy meal before bed – Eating a heavy meal before bed can cause discomfort and indigestion, making it harder to sleep. It is better to have a light snack if needed.

C. Watch television in bed to fall asleep – Engaging in stimulating activities like watching television in bed can make it harder to relax and fall asleep. It is recommended to reserve the bed for sleep and intimacy only to associate it with rest.

D. Exercise in the evening – Exercise increases alertness and can elevate body temperature, making it more difficult to fall asleep if done too close to bedtime. Exercise should be completed earlier in the day for better sleep quality.

E. Try to go to bed and awaken at the same time every day – Consistency in sleep-wake times helps regulate the body's internal clock, improving sleep quality and promoting better sleep hygiene.

F. Avoid alcohol in the evening – Alcohol can initially make someone feel sleepy but disrupts the later stages of sleep, leading to poor sleep quality. Avoiding alcohol, especially close to bedtime, is important for better rest.

G. Take an analgesic before bed – Unless there is a specific medical reason, taking an analgesic (such as pain medication) before bed is not recommended unless prescribed by a healthcare provider.

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A client on a mechanical soft diet is experiencing constipation and asks the nurse for a glass of prune juice. After auscultating decreased bowel sounds, which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["D","E"]

Explanation

Exhibits Which other recommendation(s) could the nurse give to help the client have better sleep? Select all that apply.

Correct Answer is ["A","E","F"]

Explanation

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A client on a mechanical soft diet is experiencing constipation and asks the nurse for a glass of prune juice. After auscultating decreased bowel sounds, which action should the nurse implement?