A nurse is collecting data on a client who reports only being able to tolerate drinking small amounts and having diarrhea for several days. Which of the following findings should the nurse expect?

Rigid abdomen

Decreased bowel sounds

Hypothermia

Dehydration

Answer and Explanation

The Correct Answer is D

A. Rigid abdomen: A rigid abdomen suggests peritonitis or another surgical emergency, not dehydration.

B. Decreased bowel sounds: Diarrhea usually causes hyperactive bowel sounds, not decreased.

C. Hypothermia: Clients with diarrhea or fluid loss usually present with normal or elevated temperatures, especially if infection is involved.

D. Dehydration: Diarrhea and limited fluid intake lead to dehydration, which presents with dry mucous membranes, increased thirst, tachycardia, and concentrated urine.

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Correct Answer is C

Explanation

A. Notify the provider: While important, this is not the first step. The nurse should assess the equipment before escalation.

B. Administer a prescribed analgesic: There's no indication of pain or need for analgesia at this point. It doesn’t address the lack of output.

C. Determine if there is a kink in the tubing: This is a priority action using the nursing process (Assess first). A kink or blockage is a common and correctable cause of no output.

D. Offer oral fluids: Increasing oral intake won’t help if there's an obstruction in the catheter. First assess and resolve the mechanical issue.

A. Assist the client to the left Sims' position. B. Put on sterile gloves. C. Hang the enema container 61 cm (24 in) above the anus D. Insert the tubing about 15 cm (6 in) into the anus.

Correct Answer is A

Explanation

A. Assist the client to the left Sims' position: This position uses gravity to promote flow into the rectum and colon and allows the enema to follow the natural direction of the colon.

B. Put on sterile gloves: Clean gloves are sufficient for enema administration. This is a clean, not sterile, procedure.

C. Hang the enema container 61 cm (24 in) above the anus: The correct height is no more than 45 cm (18 inches) to prevent rapid flow and discomfort.

D. Insert the tubing about 15 cm (6 in) into the anus: Insertion should be 7.5 to 10 cm (3 to 4 inches) in adults. Inserting 6 inches increases the risk of injury.

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A nurse is collecting data on a client who reports only being able to tolerate drinking small amounts and having diarrhea for several days. Which of the following findings should the nurse expect?

Nursing Test Bank

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