A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care?

Patient will have one soft, formed bowel movement by end of shift.

Patient will not take any pain medications this shift.

Patient will walk unassisted to bathroom by the end of shift.

Patient will be offered laxatives or stool softeners this shift.

Answer and Explanation

The Correct Answer is A

A. This outcome is specific, measurable, and directly addresses the goal of managing constipation by aiming for a bowel movement.
B. Discontinuing pain medication abruptly may be unrealistic and can cause distress for the patient.
C. Ambulation may help with constipation but does not directly measure or ensure bowel movement.
D. Offering laxatives or stool softeners is an intervention rather than a measurable patient outcome.

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Correct Answer is ["A","B","C","D","F"]

Explanation

A. Applying knowledge of disease processes is essential in preventing the spread of infections and understanding transmission routes.

B. Proper disposal of supplies is crucial in minimizing the risk of cross-contamination and infection spread.

C. Checking the negative-pressure system is critical to ensure it functions properly to contain airborne pathogens.

D. Hand hygiene is a key practice in preventing infection and should be performed before and after patient contact in both scenarios.

E. This statement is misleading; while some precautions may overlap, there are specific differences that must be addressed in interventions for airborne versus contact precautions.

F. It is important for patients in airborne precautions to wear a mask during transportation to prevent the spread of infectious particles.

A. Weak quadriceps muscles B. Decreased deep tendon reflexes C. Tingling of extremities with possible tetany D. Light-headedness when standing up

Correct Answer is C

Explanation

A. Weak quadriceps muscles can occur with electrolyte imbalances, but the provided values do not indicate hypokalemia or other issues causing muscle weakness.
B. Decreased deep tendon reflexes are generally associated with elevated calcium levels or other electrolyte disturbances but are not specifically indicated by the given lab values.
C. A calcium level of 4.5 mg/dL is significantly low (normal range is typically around 8.5-10.5 mg/dL), which can lead to hypocalcemia symptoms such as tingling of the extremities and tetany due to increased neuromuscular excitability.
D. Light-headedness when standing up (orthostatic hypotension) is more related to fluid volume status or dehydration rather than directly related to the given electrolyte levels.

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A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D","F"]

Explanation

Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL?

Correct Answer is C

Explanation

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