Exhibits
Review H and P, nurse's note, flow sheet, and orders.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Potential condition
Opioid-induced constipation
The client’s report of no bowel movement since surgery, along with the use of morphine for pain management, suggests opioid-induced constipation. Opioids are known to slow down gastrointestinal motility.
Actions to Take:
Administer a stool softener
Stool softeners can help ease bowel movements by softening the stool, which is a common intervention for constipation, particularly opioid-induced.
Ask the client about ambulation
Encouraging ambulation is an effective way to stimulate gastrointestinal motility and reduce the risk of constipation.
Parameters to Monitor:
Fluid intake
Adequate hydration is crucial for maintaining proper bowel function, especially when using stool softeners or other constipation treatments.
Intraabdominal pressure
Monitoring intraabdominal pressure can help assess for severe constipation or potential complications, such as bowel obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A client with a positive Mantoux test and positive sputum cultures for acid-fast bacillus (AFB) indicates tuberculosis (TB), which requires airborne precautions due to its highly contagious nature. Negative airflow rooms are essential for preventing the spread of TB.
B. Herpes simplex II is transmitted through direct contact and does not require airborne precautions; standard precautions are sufficient.
C. Scarlet fever, while contagious, requires droplet precautions and not airborne precautions, so a negative airflow room is not necessary for these clients.
D. Scabies is transmitted through direct contact and requires contact precautions rather than airborne precautions.
Correct Answer is C
Explanation
A. Tomato juice may contain high sodium levels, which is not ideal for a hypertensive diet.
B. Dill pickles and black olives are typically high in sodium, which can exacerbate hypertension.
C. A plain baked sweet potato is low in sodium and high in potassium, making it a suitable choice for someone with hypertension.
D. Canned chicken broth often contains high levels of sodium, which is not recommended for hypertension management.
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