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: 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.

Choice A rationale

Increased BUN and serum creatinine are not typically symptoms of mononucleosis. These laboratory findings are more commonly associated with kidney dysfunction.

Choice B rationale

Ear pain and fever can be symptoms of many illnesses, including mononucleosis. However, they are not the most specific symptoms of this condition.

Choice C rationale

A positive Epstein-Barr virus test and malaise are common symptoms of mononucleosis. The Epstein-Barr virus is the most common cause of mononucleosis.

Choice D rationale

Elevated WBC and sedimentation rate can be seen in many inflammatory or infectious conditions, including mononucleosis. However, they are not the most specific symptoms of this condition.