A nurse is contributing to the plan of care of a client who has a small bowel obstruction. Which of the following interventions should the nurse include?
Provide bulk-forming agent.
Elevate the head of the bed.
Measure abdominal girth daily.
Monitor intake and output every 8 hr.
The Correct Answer is B
Choice A: Provide bulk-forming agent. This is incorrect because bulk-forming agents are used to treat constipation, not bowel obstruction. They can worsen the obstruction by increasing the stool volume and pressure in the bowel.
Choice B: Elevate the head of the bed. Elevating the head of the bed is an important intervention for clients with a small bowel obstruction. It can help reduce abdominal pressure, promote comfort, and facilitate better respiratory function, especially if the client is experiencing any associated nausea or vomiting. This position can also aid in the proper positioning of the intestines, potentially helping with any non-complicated obstructions.
Choice D: Monitor intake and output every 8 hr. This is incorrect because monitoring intake and output is not enough to assess the fluid and electrolyte balance of a client with a bowel obstruction. The nurse should monitor intake and output more frequently, such as every 4 hr or every shift, and report any signs of dehydration or imbalance.
Choice C: Measure abdominal girth daily. While this is an important assessment for monitoring the status of the obstruction, the immediate intervention of elevating the head of the bed can provide immediate comfort and support during the acute phase of the obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Roast chicken with white rice is a low-fiber, easy-to-digest meal that is suitable for a client who has recovered from the acute phase of diverticulitis. A low-fiber diet can help reduce the stress on the colon and allow it to heal. White rice is a refined grain that has less fiber than whole grains, such as brown rice or quinoa12.
Choice B reason: A poached egg with sliced tomatoes is not a good choice for a client who has recovered from the acute phase of diverticulitis. Although eggs are a good source of protein and do not contain fiber, tomatoes are high in fiber and may irritate the colon. Tomatoes also have seeds, which were previously thought to cause problems for people with diverticular disease, but there is no evidence to support this. However, some people may still find them uncomfortable to eat13.
Choice C reason: Bean soup with steamed broccoli is not a good choice for a client who has recovered from the acute phase of diverticulitis. Beans and broccoli are both high in fiber and may cause gas, bloating, and cramping in the colon. A high-fiber diet is recommended for people with diverticulosis (the presence of pouches without inflammation) to prevent constipation and diverticulitis, but it should be avoided during or shortly after an episode of diverticulitis12.
Choice D reason: Ham sandwich on white bread is not a good choice for a client who has recovered from the acute phase of diverticulitis. Although white bread is low in fiber, ham is a processed meat that may increase the risk of developing diverticular disease. Research suggests that a diet high in red meat and processed meat may contribute to inflammation and infection of the pouches in the colon.
Correct Answer is D
Explanation
Choice A reason: Insulin injected into the thigh is not the most rapidly absorbed. The abdomen is the preferred site for insulin injection, as it has the fastest and most consistent absorption rate. The thigh, arm, and butock have slower and more variable absorption rates12.
Choice B reason: The botle of insulin should not be shaken before withdrawing the medication. Shaking can damage the insulin molecules and affect their potency and effectiveness. Instead, the botle should be gently rolled between the palms to mix the insulin evenly13.
Choice C reason: Lantus insulin should not be used immediately before each meal. Lantus is a long-acting insulin that provides a steady basal level of insulin for 24 hours. It should be taken once a day at the same time every day, regardless of meals. Humalog is a rapid-acting insulin that can be used immediately before each meal to cover the postprandial glucose spikes14.
Choice D reason: Unopened vials of insulin should be kept in the refrigerator until needed. This can help preserve their quality and potency until their expiration date. Opened vials of insulin can be kept at room temperature for up to 28 days, depending on the type and brand
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today