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 B

Explanation

A. Compare muscle strength bilaterally is not the most immediate concern. Although muscle weakness is a potential sign of hypokalemia, the priority is assessing for cardiac complications, as potassium imbalances can cause life-threatening arrhythmias.

B. Determine apical heart rate and rhythm is the most important intervention. A potassium level of 2.5 mEq/L is dangerously low and can lead to life-threatening cardiac arrhythmias. The nurse should assess the heart rate and rhythm to detect any abnormalities such as bradycardia, tachycardia, or irregular rhythms, which are common in hypokalemia.

C. Observe color and amount of urine is not the priority. While renal function is important, the immediate concern in this case is the potential for severe cardiac complications due to the low potassium level.

D. Assess strength of deep tendon reflexes is important for detecting signs of hypokalemia, but it is secondary to assessing the heart, as potassium imbalances primarily affect cardiac function.

A. Notify information services department of the situation. B. Wait for notification that the system has been rebooted. C. Identify information as late entry in the record. D. Print electronic medical record (EMR) from backup server.

Correct Answer is A

Explanation

A. Notify information services department of the situation is the correct first step. The nurse should immediately report the issue to the information services department to resolve the problem with the computer system. This ensures that the issue is addressed promptly and minimizes any delays in documentation or patient care.

B. Wait for notification that the system has been rebooted is not the best action. While waiting for the system to reboot might be necessary, the nurse should first notify the information services department to expedite the resolution of the issue.

C. Identify information as late entry in the record may be necessary once the system is restored, but the immediate priority is to report the system failure so that it can be addressed and the documentation can be completed correctly.

D. Print electronic medical record (EMR) from backup server may be an option if the system cannot be restored, but the first step should be to notify the information services department. The backup server can be used if needed after the issue is reported.

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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

When assessing a client with a serum potassium level of 2.5 mEq/L (2.5 mmol/L), which intervention is most important for the nurse to implement?

Correct Answer is B

Explanation

The nurse is documenting wound care in a client's electronic medical record (EMR) when the computer system shuts down. Which action should the nurse implement first?

Correct Answer is A

Explanation

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