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The client had a large, loose stool.

Vital signs: Temperature 98.7°F (37°C) orally. Heart rate 73 beats/minute.

Blood pressure 144/82 mm Hg. The client had a large, loose stool. The client had a large, loose stool.

Place the client on contact precautions.

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, and two parameters to assess the client’s progress.

Answer and Explanation

The Correct Answer is []

The correct answer is Potential Condition:

A. Secretory diarrhea.

Actions to Take:

A. Collect stool for culture.

D. Make the client NPO.

Parameters to Monitor:

A. Heart rate.

B. Serum potassium.

Potential Condition A rationale:

Secretory diarrhea is characterized by large volumes of watery stool and can be caused by infections, toxins, or certain medications. It is important to identify the underlying cause to provide appropriate treatment. Potential Condition B rationale:

Steatorrhea is characterized by fatty stools and is typically associated with malabsorption syndromes. The client’s symptoms do not suggest this condition. Potential Condition C rationale:

Motility diarrhea is caused by rapid transit of stool through the intestines, often due to conditions like irritable bowel syndrome. The client’s symptoms are more consistent with secretory diarrhea. Potential Condition D rationale:

Osmotic diarrhea occurs when non-absorbable substances draw water into the intestines. The client’s symptoms are more indicative of secretory diarrhea. Action A rationale:

Collecting stool for culture helps identify any infectious agents that may be causing the diarrhea, allowing for targeted treatment. Action B rationale:

Starting a high-fiber diet is not appropriate for a client with acute diarrhea, as it may exacerbate symptoms. Action C rationale:

Administering an oral steroid is not indicated for the treatment of secretory diarrhea and may worsen the condition. Action D rationale:

Making the client NPO (nothing by mouth) helps to rest the gastrointestinal tract and reduce the severity of diarrhea. Parameter A rationale:

Monitoring heart rate is important as dehydration from diarrhea can lead to tachycardia. Parameter B rationale:

Monitoring serum potassium is crucial as diarrhea can lead to significant electrolyte imbalances, including hypokalemia. Parameter C rationale:

Monitoring respiratory rate is not directly related to the management of diarrhea. Parameter D rationale:

Monitoring urine sodium is not directly related to the management of diarrhea.

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Correct Answer is B

Explanation

Choice A rationale
Withdrawing the medication into a syringe and labeling it with the client’s name is not necessary and could lead to errors or contamination.
Choice B rationale
Asking another nurse to witness the medication being discarded ensures proper documentation, accountability, and compliance with regulations.
Choice C rationale
Placing the vial with the remainder of the medication into a locked drawer does not address the need for proper documentation and labeling of the remaining medication.
Choice D rationale
Throwing the vial into the trash in the presence of another nurse is not appropriate as it does not ensure proper documentation, accountability, or safe storage of the remaining medication.

A. Place the client on contact precautions. B. Start a high-fiber diet. C. Administer an oral steroid. D. Make the client NPO.

Correct Answer is B

Explanation

A. Place the client on contact precautions: There is no indication of an infectious process requiring isolation. A normal glucose result does not suggest the need for precautions.
B. Start a high-fiber diet: The glucose level is within the normal range but on the higher end. Promoting a high-fiber diet can help maintain stable glucose levels and support long-term glucose control, especially if the client is at risk for impaired glucose tolerance.
C. Administer an oral steroid: Steroids can raise blood glucose levels and are not indicated in this context.
D. Make the client NPO: There is no reason to restrict oral intake based on a normal glucose result. NPO status is typically ordered for specific diagnostic procedures or when there is a risk of aspiration.

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The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL vial. Which action should the nurse perform with the remainder of the medication?

Correct Answer is B

Explanation

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Correct Answer is B

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