Before administering a laxative to a bedfast client, it is most important for the nurse to perform which assessment?

Evaluate the client's ability to recognize the urge to defecate.

Determine the frequency and consistency of bowel movements.

Observe the skin integrity of the client's rectal and sacral areas.

Assess the client's strength in moving and turning in the bed.

Answer and Explanation

The Correct Answer is B

A) Evaluate the client's ability to recognize the urge to defecate: Assessing the client's ability to recognize the urge to defecate is important for promoting independence in toileting. However, this assessment may not directly indicate the need for administering a laxative. It is more relevant for clients who are able to ambulate or have control over their bowel movements.

B) Determine the frequency and consistency of bowel movements: Assessing the frequency and consistency of bowel movements provides valuable information about the client's bowel function and helps determine the need for a laxative. It allows the nurse to establish a baseline and evaluate the effectiveness of interventions. Understanding the client's typical bowel pattern is crucial before administering a laxative to avoid overmedication or potential complications such as diarrhea or fecal impaction.

C) Observe the skin integrity of the client's rectal and sacral areas: Assessing skin integrity in the rectal and sacral areas is crucial for preventing pressure ulcers, especially in bedfast clients. However, it is not directly related to the need for administering a laxative.

D) Assess the client's strength in moving and turning in the bed: While assessing the client's strength and mobility is important for overall care and prevention of complications related to immobility, it may not be directly related to the need for administering a laxative. This assessment is more relevant for preventing complications such as pressure ulcers and maintaining musculoskeletal function.

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Correct Answer is B

Explanation

A) Increased frequency of lacrimation is not typically associated with miotic therapy. Miotics work by constricting the pupil and increasing outflow of aqueous humor to reduce intraocular pressure, but they do not directly affect lacrimation (tear production). Therefore, this option is not the etiology for the “Risk for injury” nursing problem.

B) Decreased night vision is a common side effect of miotic therapy. Miotics constrict the pupil, which can reduce the amount of light entering the eye, leading to impaired night vision or difficulty seeing in low-light conditions. This impaired vision increases the risk of injury, particularly in situations with reduced lighting.

C) Increased sensitivity to light (photophobia) is not typically associated with miotic therapy. Miotics constrict the pupil, which may actually reduce sensitivity to light by decreasing the amount of light entering the eye. Therefore, increased sensitivity to light is not the etiology for the “Risk for injury” nursing problem in this case.

D) Diminished color perception is not a common side effect of miotic therapy. Miotics primarily affect pupil constriction and intraocular pressure but do not typically alter color perception. Therefore, diminished color perception is not the etiology for the “Risk for injury” nursing problem.

Correct Answer is ["133"]

Explanation

The nurse should program the infusion pump to deliver approximately 133 ml/hour.

Here's how we can calculate the rate:

Total volume of infusion (mL): 200 mL (dextrose 5% in water)

Infusion time (minutes): 90 minutes

We need to convert the infusion time to hours for the pump rate calculation:

Infusion time (hours) = 90 minutes / 60 minutes/hour

Infusion time (hours) = 1.5 hours

Now, calculate the flow rate (mL/hr):

Flow rate (mL/hr) = Total volume (mL) / Infusion time (hours)

Flow rate (mL/hr) = 200 mL / 1.5 hours

Flow rate (mL/hr) = 133.33 mL/hr (round to nearest whole number as requested)

Therefore, the nurse should program the pump to deliver 133 ml/hour.

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Before administering a laxative to a bedfast client, it is most important for the nurse to perform which assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is receiving miotics for the treatment of open-angle glaucoma. The nurse determines that a priority nursing problem is a “Risk for injury and this is based on which etiology?

Correct Answer is B

Explanation

Correct Answer is ["133"]

Explanation

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