The nurse anticipates the need for a(n)
___
due to the client's
_
and
___
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C","dropdown-group-3":"B"}

Rationale for correct choices

• Laxative: The client is postoperative day 3 and reports not having had a bowel movement, which is common after abdominal surgery due to anesthesia, opioid use, and decreased mobility. The return of flatus indicates partial return of bowel function, making a laxative appropriate to stimulate bowel evacuation. Early management helps prevent postoperative ileus and discomfort.

• Bowel movements: Absence of bowel movements by postoperative day 3 signals delayed gastrointestinal motility. This finding indicates the need for intervention to promote normal elimination. Monitoring bowel movement patterns helps guide appropriate pharmacologic and nonpharmacologic interventions.

• Bowel sounds: The client has hypoactive bowel sounds, suggesting slowed intestinal activity following surgery. Hypoactive sounds combined with lack of bowel movement indicate decreased peristalsis rather than obstruction. This assessment finding supports the use of a laxative once flatus is present.

Rationale for incorrect choices

• Antiemetic: The client is not currently reporting nausea or vomiting. Gastrointestinal symptoms are related to decreased motility rather than upper GI upset. An antiemetic would not address constipation or delayed bowel function.

• Antidiarrheal: The client does not have diarrhea and has not had any bowel movements. Using an antidiarrheal would further slow intestinal motility and worsen constipation. This intervention would be inappropriate in the current postoperative context.

• Findings at incision site: Although purulent drainage and swelling suggest possible infection, these findings do not indicate the need for a laxative. Incisional findings are more relevant to antibiotic therapy or wound management. They do not explain delayed bowel elimination.

• Abdominal distention: The abdomen is soft and nondistended on assessment. Distention would suggest gas or obstruction, which is not present. The primary indicators remain bowel sounds and bowel movement status.

• Incisional tenderness: Incisional tenderness is expected after abdominal surgery and reflects tissue healing or inflammation. It does not directly influence bowel motility or elimination. Pain alone does not justify laxative use. This finding is unrelated to gastrointestinal function.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. "We should establish our roles in the initial session.": During the orientation phase of the therapeutic relationship, the nurse and client define the purpose of the relationship, clarify roles, and establish trust. Setting clear expectations helps the client feel safe and provides a framework for subsequent therapeutic work.

B. "Let me show you simple relaxation exercises to manage stress.": Teaching relaxation techniques occurs in the working phase of the therapeutic relationship, when the client is actively addressing anxiety symptoms and developing coping strategies. It is not the focus during orientation.

C. "We should discuss resources to implement in your daily life.": Discussing resources and practical interventions is part of the working or termination phase, after rapport has been established and the client is ready to apply strategies outside the therapeutic setting.

D. "Let's talk about how you can change your response to stress.": Exploring behavioral change and coping strategies is a component of the working phase. The orientation phase is intended for establishing trust, setting goals, and defining roles rather than implementing interventions.

A. Check for gastric residual every 12 hr. B. Place enough formula in the container to last 18 hr. C. Maintain bed elevation at 20°. D. Flush the tubing with 30 mL of water every 4 hr.

Correct Answer is D

Explanation

A. Check for gastric residual every 12 hr: Current best practices recommend checking gastric residuals every 4–6 hours for continuous feedings to assess tolerance and prevent aspiration. Checking only every 12 hours may delay recognition of feeding intolerance.

B. Place enough formula in the container to last 18 hr: Open system formulas should be changed every 4–8 hours to reduce the risk of bacterial contamination. Using formula for 18 hours increases the risk of infection and is not recommended.

C. Maintain bed elevation at 20°: To reduce the risk of aspiration, clients receiving continuous enteral feedings should have the head of the bed elevated to 30–45°, not 20°. Proper elevation helps prevent reflux and aspiration pneumonia.

D. Flush the tubing with 30 mL of water every 4 hr: Regular flushing maintains tube patency, prevents clogging, and ensures the client receives the full feeding. Flushing every 4 hours with water is consistent with safe enteral feeding practices.

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The nurse anticipates the need for a(n) _____ due to the client's _____ and _____ .

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase?

Correct Answer is A

Explanation

A nurse is planning care for a client who is receiving continuous enteral tube feedings through an open system. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is D

Explanation

A nurse is caring for a client who has urticaria following administration of an antibiotic. Which of the following medications should the nurse prepare to administer?

A nurse is reviewing a client's cardiac rhythm strips and notes a constant P-R interval of 0.35 seconds. Which of the following dysrhythmias is the client displaying?

A nurse is caring for a client who speaks a different language than the nurse. Which of the following actions should the nurse take when communicating with the client?

A nurse is caring for a client who has an abruptio placentae. Which of the following findings should the nurse expect?

A charge nurse is monitoring a newly licensed nurse who is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following statements by the newly licensed nurse indicates an understanding of the procedure?

A nurse is providing teaching to the parents of a newborn about newborn genetic screening. Which of the following statements should the nurse include in the teaching?

A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

The nurse anticipates the need for a(n)
___
due to the client's
_
and
___
.