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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Calms spasm in the urinary tract: This statement is incorrect. Phenazopyridine primarily provides analgesic (pain-relieving) effects for the urinary tract but does not directly affect muscle spasms.
B) Provides an analgesic effect for irritated bladder mucosa: This is the correct response. Phenazopyridine is a urinary tract analgesic that acts locally to relieve pain, burning, and discomfort caused by irritation of the bladder mucosa. It does not treat the underlying infection but helps alleviate symptoms.
C) Eliminates urinary bacteria: This statement is incorrect. Phenazopyridine does not have antibacterial properties and does not eliminate urinary bacteria. Antibiotics are typically prescribed to treat urinary tract infections by targeting bacterial growth.
D) Use the medication after voiding after sexual intercourse: This statement is incorrect. While voiding after sexual intercourse can help reduce the risk of urinary tract infections (UTIs), phenazopyridine is not specifically indicated for this purpose. It is used primarily for symptom relief in cases of cystitis or other urinary tract irritations.
Correct Answer is B
Explanation
A) Notify the healthcare provider of the contraindication to tetracyclines: Tetracyclines, including doxycycline hyclate, are not contraindicated in clients taking birth control pills. While there may be interactions between these medications, they are not absolute contraindications.
B) Advise the client that the oral birth control will be less effective while taking doxycycline hyclate: Doxycycline hyclate, like other antibiotics, may reduce the effectiveness of oral contraceptives by altering the gut flora and interfering with the enterohepatic circulation of estrogen. Clients should be informed of this potential interaction and advised to use an additional form of contraception (such as condoms) while taking the antibiotic and for a period afterward.
C) Instruct the client to take the two medications at least two hours apart: While separating the administration of doxycycline hyclate and oral contraceptives by two hours may reduce the potential for interaction, it is not the standard recommendation. It is generally advised to use additional contraceptive methods during antibiotic therapy and for a period afterward, rather than relying solely on timing of medication administration.
D) Encourage the client to stop taking oral birth control until she has finished taking all the doxycycline hyclate: Stopping oral contraceptives abruptly is not recommended and may lead to unintended pregnancy. Instead, clients should be advised to use additional contraceptive methods while taking doxycycline hyclate and for a period afterward to ensure continued protection against pregnancy.
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