Exhibits
A nurse is caring for a 44-year-old male client who had an anterior-posterior spinal fusion 3 days ago. The client is experiencing uncontrolled pain and has not had a bowel movement since the surgery. Which actions should the nurse take to assess the client's progress?
Select all that apply.
Administer a stool softener
Ask the client about their normal bowel routine
Hold the client's next meal
Perform a digital rectal exam
Discontinue morphine
Correct Answer : A,B,D
. Administer a stool softener: This could be a good option to consider, as the client has not had a bowel movement since the surgery. However, the nurse should first consult with the healthcare provider before administering any new medications.
B. Ask the client about their normal bowel routine: This is a good action to take. Understanding the client’s normal bowel routine can provide valuable context for the current situation.
C. Hold the client’s next meal: This may not be necessary at this point. The client’s regular diet has been ordered by the provider, and there’s no indication of nausea, vomiting, or other symptoms that would necessitate holding meals.
D. Perform a digital rectal exam: This could be considered if there’s a concern about impaction or other complications. However, this should only be done after consulting with the healthcare provider.
E. Discontinue morphine: This is not advisable based on the information provided. The client is reporting uncontrolled pain, and morphine has been ordered by the provider for pain management. Any changes to pain medication should be discussed with the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Asking the patient how often episodes of sundowning are experienced is more relevant in assessing cognitive function, particularly in patients with dementia. It is not directly related to the patient’s weight loss or decreased energy and appetite.
Choice B rationale
Inquiring about the frequency of falls in recent months is crucial in a functional assessment of an older patient who has lost weight and reports a decrease in energy and appetite. Weight loss and decreased energy can increase the risk of falls, which can lead to serious injuries and further functional decline.
Choice C rationale
Requesting the patient to lie as still as possible for the assessment is not directly related to the patient’s weight loss or decreased energy and appetite. It might be necessary for certain physical examinations or procedures, but it is not the most relevant action in this context.
Choice D rationale
Assisting the patient with clarifying values about end-of-life care options is an important aspect of geriatric care, especially in patients with serious illnesses. However, it is not directly related to the patient’s weight loss or decreased energy and appetite.
Correct Answer is C
Explanation
Choice A rationale
While a headache with sudden onset can be a symptom of various conditions, it is not the most critical finding to report in a client with atrial fibrillation and a rapid ventricular rate.
Choice B rationale
Flat jugular vein distention (JVD) at 45 degrees is not the most critical finding to report in a client with atrial fibrillation and a rapid ventricular rate.
Choice C rationale
An abnormal level of consciousness can be a sign of decreased cerebral perfusion, which can occur in a client with atrial fibrillation and a rapid ventricular rate. This is a critical finding that should be reported to the healthcare provider immediately.
Choice D rationale
Nausea with vomiting is not the most critical finding to report in a client with atrial fibrillation and a rapid ventricular rate.
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