Six days following a minor vehicle crash, an older client returns to the emergency department to have stitches removed. While the nurse is removing the stitches, the client reports feeling bloated and not having a bowel movement since the accident. Which intervention should the nurse implement first?

Increase fiber in diet and add daily prune juice.

Perform a digital examination for fecal impaction.

Assess type and frequency of physical activities.

Check bowel sounds and abdominal tenderness.

Answer and Explanation

The Correct Answer is D

A. Increase fibre in diet and add daily prune juice: Increasing dietary fibre and adding prune juice can help promote bowel movements and relieve constipation. However, this is a long-term solution and might not address any immediate underlying issues.

B. Perform a digital examination for faecal impaction: This invasive procedure can confirm or rule out faecal impaction, which is a potential cause of severe constipation, especially in older adults. However, it's not typically the first step without further assessment.

C. Assess type and frequency of physical activities: Physical activity affects bowel motility. Assessing activity levels can provide insight into one possible cause of constipation. However, this should come after assessing more direct symptoms.

D. Check bowel sounds and abdominal tenderness: This is a non-invasive initial assessment that can provide important information about the client's bowel activity and potential obstructions. It helps determine the next steps for diagnosis and treatment.

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Correct Answer is C

Explanation

A. A bubbling sound heard during inspiration and expiration in the central airways: This description is accurate. Crackles (also called rales) are often heard in conditions like pulmonary edema or pneumonia.

B. A crowing noise heard during inspiration over the trachea: This description refers to stridor, not crackles. Stridor occurs due to upper airway obstruction.

C. Popping, non-musical sounds heard in the lung bases, usually during inspiration: This description is accurate for crackles. They occur due to fluid or secretions in the alveoli.

D. Superficial squeaking or grating sounds heard during inspiration and expiration: This description refers to wheezes, not crackles. Wheezes are associated with narrowed airways.

A. Plan to measure the blood pressure in four hours as prescribed. B. Repeat the client's blood pressure measurement in fifteen minutes. C. Obtain an automatic blood pressure machine for hourly readings. D. Reassess the blood pressure if the client reports other symptoms.

Correct Answer is B

Explanation

A. Plan to measure the blood pressure in four hours as prescribed. Waiting for another four hours may not be appropriate given the significant increase in blood pressure. Immediate action is needed to address the elevated reading.

B. Repeat the client’s blood pressure measurement in fifteen minutes. This is the most appropriate action. When a client’s blood pressure is significantly elevated, it’s essential to recheck it promptly to confirm accuracy and assess for any changes. Fifteen minutes allows enough time for a follow-up measurement without unnecessary delay.

C. Obtain an automatic blood pressure machine for hourly readings. While continuous monitoring is valuable in some situations, it’s not necessary for routine blood pressure assessments. Hourly readings would be excessive and may not provide additional useful information.

D. Reassess the blood pressure if the client reports other symptoms. While assessing other symptoms is essential, waiting for symptoms to occur before reassessing blood pressure is not the best approach. Immediate follow-up is warranted based on the elevated reading alone

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Naxlex Comprehensive Predictor Exams

The nurse hears crackles when auscultating a client's lung sounds. Which is an accurate description of the sound of crackles?

Correct Answer is C

Explanation

A client has a prescription for vital sign measurement every four hours. The nurse observes that the client's blood pressure has increased from 140/60 mm Hg at noon to 180/90 mm Hg four hours later. Which action should the nurse implement?

Correct Answer is B

Explanation

A parent brings a preschool aged client to the clinic because of having diarrhea, vomiting, and high fevers for the past three days. The child begins to cry and cling to the parent when the nurse enters the examination room. Which action should the nurse implement to get the child to cooperate?

To compare arterial circulation in a client's lower extremities, which assessment should the nurse complete?

While-interviewing an elderly client, the nurse observes that the client's hands tremble uncontrollably while reaching for a glass of water. How should the nurse document this finding?

The nurse completes palpation of the thoracic region on an adolescent client. Which finding is considered normal for this adolescent client?

The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?

During a routine health screening of an adult client, the nurse notes several changes that have occurred over the past year. Which change indicates the need for a bone density screening?