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

Answer and Explanation

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

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Correct Answer is C

Explanation

Choice A rationale

While understanding risk factors for osteoporosis is important, it is not the highest priority for an older adult client diagnosed with osteoporosis. The highest priority is ensuring the client’s safety to prevent falls and fractures.

Choice B rationale

While constipation due to immobility can be a concern for clients with osteoporosis, it is not the highest priority for an older adult client diagnosed with osteoporosis. The highest priority is ensuring the client’s safety to prevent falls and fractures.

Choice C rationale

Identifying home safety hazards to be resolved immediately is the highest priority for an older adult client diagnosed with osteoporosis. Osteoporosis increases the risk of fractures, and falls are a common cause of fractures in older adults. Therefore, ensuring a safe environment is crucial.

Choice D rationale

While adding calcium-rich foods to the daily diet can help manage osteoporosis, it is not the highest priority for an older adult client diagnosed with osteoporosis. The highest priority is ensuring the client’s safety to prevent falls and fractures.

A. Blood pressure of 100/60 mm Hg. B. Presence of hematemesis. C. Incontinence with blood in urine. D. Unresponsiveness to painful stimuli.

Correct Answer is B

Explanation

Choice A rationale

A blood pressure of 100/60 mm Hg is not typically considered a risk for patients receiving eptifibatide. While eptifibatide can cause hypotension, a blood pressure of 100/60 mm Hg is within normal limits.

Choice B rationale

The presence of hematemesis, or vomiting blood, poses the greatest risk to the patient. Eptifibatide is a glycoprotein IIb/IIIa inhibitor that prevents platelets from clumping together by blocking the action of certain proteins. This can increase the risk of bleeding, including gastrointestinal bleeding, which could manifest as hematemesis.

Choice C rationale

Incontinence with blood in the urine could indicate a urinary tract infection or other urinary system issue, but it is not typically associated with the use of eptifibatide.

Choice D rationale

Unresponsiveness to painful stimuli is a serious symptom that could indicate a number of issues, including neurological damage or severe illness. However, it is not typically associated with the use of eptifibatide.

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Naxlex Comprehensive Predictor Exams

The nurse is preparing a teaching plan for an older adult client diagnosed with osteoporosis.Which expected outcome has the highest priority for this client?

Correct Answer is C

Explanation

A patient admitted with an acute coronary syndrome (ACS) is receiving eptifibatide, a glycoprotein (GP) IIb IIIa inhibitor.Which assessment finding poses the greatest risk to the patient?

Correct Answer is B

Explanation

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