The nurse is completing an assessment of an older adult client recovering from a total hip replacement. The client reports a decreased appetite and is concerned about having not had a bowel movement for several days. Which intervention should the nurse implement first?

Increase fiber in diet and add daily prune juice.

Assess type and frequency of physical activities.

Perform a digital examination for fecal impaction.

Check bowel sounds and abdominal tenderness.

Answer and Explanation

The Correct Answer is D

A.   Increasing dietary fiber and adding prune juice can help relieve constipation by improving bowel regularity. While this is an important step in managing constipation, it is not the first action to take without understanding the underlying cause or current status of bowel function.
B.   Physical activity is important for bowel regularity, especially post-surgery. However, assessing physical activity should come after a more immediate evaluation of the client's bowel status. It is crucial to first determine if there are other underlying issues that need addressing before implementing dietary changes or increasing activity.
C.   A digital examination can be necessary to identify fecal impaction, especially if other assessments suggest severe constipation or if the client has not had a bowel movement for several days. However, this is an invasive procedure and should be performed based on preliminary findings from non-invasive assessments.
D.   Checking bowel sounds and abdominal tenderness is an essential first step in assessing the client's gastrointestinal status. It helps identify whether there is a lack of bowel movement due to a more severe issue such as bowel obstruction or if it is simply a case of constipation.

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Correct Answer is B

Explanation

A. Assessing whether the expected outcomes were realistic involves evaluating if the goals set in the plan of care were achievable given the client’s condition, resources, and constraints. While this is an important consideration, it is not the immediate next step after reviewing the expected outcomes.
B. After reviewing the expected outcomes, the next critical step is to gather and analyze current client data. This includes assessing the client’s current condition, symptoms, and responses to interventions. By comparing this data with the expected outcomes, the nurse can determine if the goals are being met, if they need adjustment, or if different interventions are required.
C. Reviewing professional standards of care involves understanding the accepted norms and guidelines for nursing practice. While important, this action typically precedes the direct evaluation of care and is part of ensuring that the care plan was developed and implemented according to professional guidelines.
D. Modifying nursing interventions is an action that might be required if the evaluation shows that the expected outcomes are not being met. However, this action is taken after evaluating the effectiveness of the current interventions by comparing client data with expected outcomes.

A. Assess the client for pain. B. Apply wrist restraints. C. Determine the client's blood pressure. D. Administer a mild sedative.

Correct Answer is A

Explanation

A. Assessing the client for pain is a crucial step because pain can cause disorientation and agitation, especially after surgery. Pain might be a reason for the client's behavior. Addressing pain effectively can help improve the client’s comfort and potentially reduce disorientation and risky behavior.
B. Applying wrist restraints should be considered a last resort and only when other interventions are not effective or if there is an immediate danger to the client. Restraints can increase agitation and potentially lead to other complications.
C. Determining the client's blood pressure can be important, especially if there are concerns about hypotension or other cardiovascular issues that might contribute to disorientation. However, it is usually more effective to first address potential pain or discomfort.
D. Administering a sedative may be appropriate in cases of severe agitation or disorientation, but it should not be the first action. It is essential to first identify and address any underlying causes of the client’s behavior, such as pain, before resorting to pharmacological interventions.

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The nurse is completing an assessment of an older adult client recovering from a total hip replacement. The client reports a decreased appetite and is concerned about having not had a bowel movement for several days. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?

Correct Answer is B

Explanation

On the first postoperative day, the nurse finds an older adult client disoriented and trying to climb over the bed railing. The client was oriented to person, place, and time on admission. Which intervention should the nurse implement first?

Correct Answer is A

Explanation

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The nurse is completing an assessment of an older adult client recovering from a total hip replacement. The client reports a decreased appetite and is concerned about having not had a bowel movement for several days. Which intervention should the nurse implement first?

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