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 D

Explanation

A. This action involves assessing which staff members are appropriately equipped to handle the situation. While it is useful to know which staff are fitted with particulate filter masks, this step does not directly address the UAP’s immediate concern or resolve the issue with the current assignment.
B. Pertussis (whooping cough) is a disease that requires droplet precautions, which generally means using a standard surgical mask rather than a particulate filter mask. However, it’s crucial to ensure that the UAP is aware of and follows the correct infection control measures.
C. Pertussis requires droplet precautions, which usually involve wearing a standard surgical mask, not a particulate filter mask (N95). Fitting for an N95 mask is generally reserved for airborne precautions.
D. This action addresses the immediate need by allowing the UAP to perform tasks that do not involve close personal care (such as taking vital signs) with a standard face mask, which is appropriate for droplet precautions. It also ensures that the UAP receives proper fitting for a particulate filter mask if needed for other tasks or future assignments.

A. Determine which medications may be given in generic form rather than brand name only. B. Provide client teaching regarding the desired effects of the client's admission prescriptions. C. Reconcile prescribed medication dosages with the published recommended dosage ranges. D. Compare admission prescriptions with the list of medications previously taken by the client.

Correct Answer is D

Explanation

A. While determining if medications can be given in generic form can be a cost-effective measure and might be beneficial for the client, it is not the most urgent action to take during the admission process. The primary focus should be on ensuring that the medications are correct, safe, and appropriate for the client’s current condition and needs.
B. Client education about the desired effects of medications is important for ensuring the client understands their treatment and can identify any side effects or issues. However, this is typically done after ensuring that the medication list is accurate and reconciled. Teaching should be part of a comprehensive plan once the medication list and dosages are confirmed.
C. Reconciliation of prescribed medication dosages with recommended dosage ranges is important for ensuring the client receives appropriate and safe dosages. However, this action is part of a broader process of medication reconciliation, which involves verifying and comparing the current list of medications against previous records and established guidelines.
D. Comparing admission prescriptions with the list of medications previously taken by the client is a crucial first step in the medication reconciliation process. This action ensures that there is no duplication, omission, or incorrect change in the medication regimen. It helps prevent potential medication errors and ensures continuity of care.

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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

Correct Answer is D

Explanation

An older client is being admitted to a rehabilitation unit from a medical-surgical unit following a left hip replacement. When reviewing the client's prescribed medications, which intervention should the nurse implement first?

Correct Answer is D

Explanation

The nurse assesses an older adult client's ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client's posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

When establishing a therapeutic environment for an older adult client, which intervention is most important for the nurse to implement?

An older adult client is admitted to a long term care facility. Upon admission, the client is oriented but fatigued, is incontinent of urine, and has a stage II pressure ulcer on the left heel. Which additional finding requires further assessment?

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?

The nurse is preparing to feed a newly admitted older adult client who is debilitated, but is able to respond to most commands. Before starting to feed the client, which information is most important for the nurse to obtain?

The nurse assesses a client who has a nasal cannula delivering oxygen at 2 liters/minute. To assess for skin damage related to the cannula, what areas should the nurse observe? Select all that apply.

The nurse finds a confused client wandering in the hallway during the night. Which actions should the nurse implement? Select all that apply.