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 C

Explanation

A. Turgor is not a reliable indicator of fluid balance in clients with fluid volume overload, as it is more commonly used to assess dehydration.

B. Blood pressure is affected by fluid volume but is not a direct or specific measure of fluid balance. Other factors, such as medication or underlying conditions, can influence blood pressure.

C. Weight is the most accurate and sensitive indicator of fluid balance. A change in weight directly correlates with fluid retention or loss, making it the preferred method for evaluating fluid balance.

D. Lung sounds can indicate fluid overload if crackles are present, but they are not a quantitative measure of fluid balance and do not provide ongoing assessment of fluid changes.

A. The client will adhere to the medication regimen after discharge. B. The client attempts to self-administer insulin but is unable to perform injection. C. The client will demonstrate ability to change the ostomy bag in two days. D. The client's breath sounds will be auscultated by the nurse every 4 hours.

Correct Answer is A

Explanation

A. The client will adhere to the medication regimen after discharge is an appropriate outcome statement because it is specific to the client's need to manage hyperglycemia with insulin therapy postoperatively. This outcome addresses the necessity of learning self-injection techniques and adhering to the prescribed regimen.

B. The client attempts to self-administer insulin but is unable to perform injection is not an appropriate outcome statement because it does not reflect a desired or achievable goal. It implies failure rather than a measurable improvement.

C. The client will demonstrate ability to change the ostomy bag in two days is relevant to the colostomy care but does not address the immediate need for managing hyperglycemia with insulin therapy.

D. The client's breath sounds will be auscultated by the nurse every 4 hours is a task-oriented intervention rather than a client-centered outcome statement.

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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

A client with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the client's fluid balance?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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