The nurse is caring for a hospitalized client who has not had a bowel movement in 3 days and reports abdominal discomfort. Which nursing intervention is most appropriate to address the client's constipation?

Administer a daily multivitamin with iron.

Encourage the client to remain in bed and limit ambulation

Increase the client's fluid intake and encourage high-fiber foods.

Withhold food and fluids until bowel sounds return.

Answer and Explanation

The Correct Answer is C

Rationale:
A. A multivitamin with iron may actually worsen constipation, as iron can be constipating.
B. Limiting ambulation contributes to decreased gastrointestinal motility and worsens constipation.
C. Increasing fluid intake and encouraging high-fiber foods are evidence-based interventions to promote bowel regularity and relieve constipation. This is the most appropriate nursing intervention.
D. Withholding food and fluids is unnecessary unless there are signs of bowel obstruction or ileus, which are not indicated in this scenario.

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Correct Answer is B

Explanation

Rationale:
A. Rectal temperatures should be avoided in clients with thrombocytopenia due to the risk of mucosal trauma and bleeding.
B. Using a soft toothbrush helps prevent gum injury and bleeding, which is essential in clients with low platelet counts. This is a correct and important safety measure.
C. A straight-edge razor poses a high risk for cuts; an electric razor should be used instead to minimize bleeding risk.
D. There is no need to limit fruit consumption unless the client is also neutropenic, in which case raw or unwashed produce might be restricted. Fruit intake is not a bleeding risk.

A. The salad bar is a healthy choice when dining out. B. Bottled water is a suitable choice for increasing fluid intake. C. A fresh green salad with raw spinach, tomatoes, and cucumbers is a healthy choice for this client. D. Eating at a buffet is a good choice to increase caloric intake.

Correct Answer is B

Explanation

Rationale:
A. Salad bars can be a source of bacteria and are not recommended for neutropenic clients due to the high risk of infection from improperly washed or handled foods.
B. Bottled water is a safe option for clients with neutropenia, as it reduces exposure to potential contaminants found in tap water.
C. Raw vegetables, including spinach, tomatoes, and cucumbers, carry a higher risk of bacterial contamination and should be avoided by neutropenic patients.
D. Buffets pose a risk of exposure to pathogens due to prolonged food sitting time and shared serving utensils, making them unsafe for immunocompromised clients.

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The nurse is caring for a hospitalized client who has not had a bowel movement in 3 days and reports abdominal discomfort. Which nursing intervention is most appropriate to address the client's constipation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is creating a teaching plan for a client who has thrombocytopenia. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

A nurse is preparing a teaching plan for a client who has neutropenia as a result of radiation therapy for the treatment of lung cancer. Which of the following should the nurse plan to include in the teaching?

Correct Answer is B

Explanation

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