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 A

Explanation

A. Developing self-awareness of personal values is crucial for a nurse acting as an advocate. It ensures
that the nurse’s own beliefs and biases do not interfere with representing the client's wishes and values. This self-awareness helps the nurse advocate effectively for the client’s preferences and decisions without imposing their own personal values.
B. While listening to the ethics committee discussions is important for understanding the context of the ethical dilemma, informing the client about what actions should be taken might not align with the nurse’s role as an advocate. The nurse's role is to represent the client's wishes and interests, not to dictate actions based on the committee’s deliberations.
C. It is important to ensure the client’s wishes are represented, but challenging team members should be done respectfully and constructively. The nurse should focus on presenting the client’s viewpoint clearly and facilitating a discussion that considers the client’s preferences.
D. Educating the client about current literature can be helpful, but it is not the primary responsibility of the nurse in the role of an advocate at an ethics committee meeting. The nurse’s primary role is to
represent the client’s wishes and ensure their voice is heard in the ethical decision-making process.

A. Establish mental status baseline. B. Insert an indwelling urinary catheter. C. Check the accuracy of medication list. D. Obtain a capillary blood glucose level.

Correct Answer is D

Explanation

A. While establishing a mental status baseline is important for assessing the client's overall neurological condition and any potential changes in consciousness or cognition, it is not the immediate priority in this case.
B. Inserting a urinary catheter might be necessary for monitoring urine output, especially if there are concerns about fluid balance or kidney function. However, it is not the immediate priority in this scenario unless there are signs of urinary retention or output issues.
C. Checking the accuracy of the medication list is important for understanding the client's current treatment regimen and any possible drug interactions or errors. However, this action does not directly address the urgent symptoms of fever, nausea, vomiting, and blurred vision, which could be indicative of a more immediate medical issue.
D. Given the client’s history of insulin-dependent diabetes mellitus and the presenting symptoms, obtaining a capillary blood glucose level is the most critical and immediate intervention. The symptoms of fever, nausea, vomiting, and blurred vision can be associated with hyperglycemia (high blood glucose) or hypoglycemia (low blood glucose).

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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

The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

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