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 B
Explanation
A. While the nursing staff should be aware of the DNR status, the immediate concern is the client's expressed wishes regarding treatment.
B. Notifying the healthcare provider is essential so that the medical team can respect the client’s wishes, especially in an acute situation where life-saving measures are being discussed.
C. Placing a certified copy of the living will in the record is important, but it should be done after informing the healthcare provider.
D. Facilitating a family meeting may be helpful, but the priority is to communicate the client's wishes to the medical team immediately.
Correct Answer is D
Explanation
A. Client A's oxygen saturation of 94% is within an acceptable range for someone with emphysema, and increasing oxygen may not be necessary at this time.
B. Moving Client D into an isolation room may not be necessary based solely on the elevated WBC count, which could indicate an infection but does not mandate isolation without additional symptoms.
C. Client C’s potassium level of 3.8 mEq/L is within the normal range, so there is no urgent need to add a banana.
D. Verifying that Client B has two units of packed cells available is critical due to the low postoperative hemoglobin level, indicating a need for potential transfusion.
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