A nurse is admitting a client who reports having diarrhea for the past 72 hr. Which of the following actions is the nurse's priority?

Provide oral replacement solution.

Obtain a prescription for antidiarrheal medication.

Offer the client a sitz bath.

Collect a specimen of the client's stool.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Providing oral replacement solution is the nurse's priority in this situation. Diarrhea can lead to dehydration and electrolyte imbalances due to fluid loss. Oral rehydration solutions contain electrolytes and fluids that can help restore the body's hydration balance. Ensuring the client's adequate fluid intake takes precedence in preventing complications associated with diarrhea.

Choice B rationale:

Obtaining a prescription for antidiarrheal medication is important, but it is not the priority action. The client's dehydration and electrolyte imbalance should be addressed first through oral rehydration before focusing on symptom management.

Choice C rationale:

Offering the client a sitz bath is not the priority action for someone experiencing diarrhea. Sitz baths are typically used for conditions affecting the perineal area, such as hemorrhoids or perineal discomfort. However, in the case of diarrhea, the primary concern is managing fluid and electrolyte balance.

Choice D rationale:

Collecting a specimen of the client's stool is important for diagnostic purposes, but it is not the immediate priority. The client's hydration status and electrolyte balance should be addressed promptly to prevent complications. Stool collection can be considered once the client's hydration has been stabilized.

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Correct Answer is C

Explanation

Choice A rationale:

Positioning the client so that they are lying flat (Choice A) is not the appropriate action after evisceration. Evisceration is the protrusion of internal organs through a wound, and lying flat could potentially put pressure on the exposed organs and worsen the situation.

Choice B rationale:

Increasing the client's oral fluid intake (Choice B) is generally a good practice for postoperative care, but it is not the priority in the case of evisceration. The primary concern is protecting the exposed organs and preventing infection.

Choice C rationale:

Preparing the client for emergency surgery (Choice C) is the correct action after observing evisceration. Evisceration is a surgical emergency, and the client needs immediate medical intervention to repair the wound and secure the exposed organs.

Choice D rationale:

Applying gentle pressure to the dressed wound (Choice D) is contraindicated in the case of evisceration. Applying pressure could further damage the exposed organs and increase the risk of infection.

A. MSO4 4 mg IV bolus daily before dressing changes and dilute with 5 cc of water. B. Morphine 4 mg IV bolus daily at 0900 before dressing changes, dilute medication with 5 mL of sterile water. C. Morphine 4 mg IV bolus Q.D. before dressing changes and dilute with 5 cc of sterile water. D. MSO4 4 mg IV bolus daily @9 AM, dilute with 5 mL of sterile water.

Correct Answer is B

Explanation

Choice A rationale:

While the abbreviation "MSO4" represents morphine sulfate, it is safer to spell out the medication name to prevent misinterpretation. Also, the use of "cc" for volume and lack of clarity in timing make this option less desirable.

Choice B rationale:

(Correct Choice) This option correctly identifies the medication, includes the dose (4 mg), specifies the route (IV), indicates the timing (daily at 0900 before dressing changes), and provides instructions for dilution (5 mL of sterile water).

Choice C rationale:

Using "Q.D." is an abbreviation for "every day" and might lead to confusion due to unfamiliarity. Additionally, using "cc" instead of "mL" and lack of clarity in timing reduce the accuracy of this transcription.

Choice D rationale:

Using "MSO4" and "cc" are potential sources of confusion. Also, the abbreviation "@9 AM" might not be universally understood, and "mL" is a more appropriate unit for volume.

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A nurse is admitting a client who reports having diarrhea for the past 72 hr. Which of the following actions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a postoperative client and observes evisceration of the abdominal surgical wound. After covering the wound with a sterile, saline-soaked dressing, which of the following actions should the nurse take?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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