A patient at a long-term care facility makes the following statements regarding management of his constipation. Which statement would require follow-up teaching by the nurse?

I try to walk in the hallway each day with assistance.

I need to increase fiber in my diet and drink more water.

I take my laxative every morning and an enema every night.

The pain medication I take tends to make my constipation worse.

Answer and Explanation

The Correct Answer is C

Choice A reason: I try to walk in the hallway each day with assistance is a correct statement. Walking is a form of physical activity that can stimulate bowel movements and prevent constipation. Walking also has other benefits such as improving circulation, muscle strength, and mood. The patient should be encouraged to walk as much as possible with assistance to prevent falls and injuries.

Choice B reason: I need to increase fiber in my diet and drink more water is a correct statement. Fiber is a type of carbohydrate that is not digested by the body and helps to form soft and bulky stools. Fiber can be found in foods such as fruits, vegetables, whole grains, nuts, and seeds. Water is essential for hydration and helps to soften the stools and ease their passage. The patient should be advised to consume at least 25 grams of fiber and 8 glasses of water per day to prevent constipation.

Choice C reason: I take my laxative every morning and an enema every night is an incorrect statement that requires follow-up teaching by the nurse. Laxatives and enemas are medications that are used to treat constipation by stimulating or lubricating the bowel. However, they should not be used routinely or excessively, as they can cause side effects such as dehydration, electrolyte imbalance, abdominal cramps, diarrhea, or dependence. The patient should be instructed to use laxatives and enemas only as prescribed by the doctor and for a short period of time. The patient should also be informed of the potential risks and complications of overusing laxatives and enemas.

Choice D reason: The pain medication I take tends to make my constipation worse is a correct statement. Pain medications, especially opioids, can slow down the movement of the bowel and cause constipation. This is a common and expected side effect of pain medications. The patient should be educated on how to manage constipation caused by pain medications, such as increasing fiber and water intake, exercising regularly, and using stool softeners or laxatives as needed. The patient should also be reassured that constipation does not mean that the pain medication is not working or that they are addicted to it.

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Correct Answer is D

Explanation

Choice A reason: Nurses can accomplish more if they perform the easiest or fastest interventions is not a primary reason for prioritizing care. This statement implies that nurses should focus on the quantity rather than the quality of care. However, nurses should prioritize care based on the urgency and complexity of the patient's needs, not on the ease or speed of the interventions. Performing the easiest or fastest interventions may not address the most important or critical issues that the patient faces.

Choice B reason: Nurses should always perform interventions related to client preference early in the shift is not a primary reason for prioritizing care. This statement implies that nurses should base their care on the patient's wishes rather than the patient's condition. However, nurses should prioritize care based on the severity and acuity of the patient's problems, not on the patient's preference. Performing interventions related to client preference early in the shift may not be feasible or appropriate if the patient has more urgent or emergent needs that require immediate attention.

Choice C reason: Nurses need to plan how to accomplish all activities within one shift is not a primary reason for prioritizing care. This statement implies that nurses should focus on the completion rather than the quality of care. However, nurses should prioritize care based on the significance and impact of the patient's outcomes, not on the completion of the activities. Accomplishing all activities within one shift may not be possible or necessary if the patient's situation changes or if some activities can be delegated or postponed.

Choice D reason: Nurses have a limited amount of time to perform nursing interventions during a shift is a primary reason for prioritizing care. This statement acknowledges that nurses face time constraints and competing demands in their work environment. Therefore, nurses should prioritize care based on the best use of their time and resources to meet the patient's needs. Having a limited amount of time to perform nursing interventions during a shift requires nurses to make clinical judgments and decisions that optimize the patient's health and safety.

A. Stop the KCl infusion B. Administer oral KCl C. Encourage fluids for dilution D. Call the pharmacy

Correct Answer is A

Explanation

Choice A reason: This is the correct answer because stopping the KCl infusion is the first and most urgent action that the nurse should take. A high level of potassium in the blood, or hyperkalemia, can cause life-threatening cardiac arrhythmias and muscle weakness. The nurse should stop the source of excess potassium, which is the KCl infusion, and monitor the client's vital signs, electrocardiogram, and symptoms.

Choice B reason: This is not the correct answer because administering oral KCl is not the first or appropriate action that the nurse should take. Oral KCl would increase the potassium level in the blood, which is already too high. The nurse should avoid giving any potassium supplements or foods that are high in potassium, such as bananas, oranges, and potatoes.

Choice C reason: This is not the correct answer because encouraging fluids for dilution is not the first or effective action that the nurse should take. Fluids alone would not lower the potassium level in the blood, but rather dilute the concentration of other electrolytes, such as sodium and calcium. The nurse should administer fluids only as prescribed by the physician, and in conjunction with other treatments, such as diuretics, insulin, or sodium bicarbonate.

Choice D reason: This is not the correct answer because calling the pharmacy is not the first or priority action that the nurse should take. Calling the pharmacy may be necessary to obtain the medications that can lower the potassium level in the blood, such as diuretics, insulin, or sodium bicarbonate. However, the nurse should first stop the KCl infusion and notify the physician, who will order the appropriate medications and dosages.

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A patient at a long-term care facility makes the following statements regarding management of his constipation. Which statement would require follow-up teaching by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

The RN receives a call from the lab that a client's potassium chloride (KCl) level is 6.6 (normal range is 3.5 to 5 mEq/L). What should the nurse do first?

Correct Answer is A

Explanation

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