When performing a focused gastrointestinal system assessment, the practical nurse (PN) asks a male client when his last bowel movement occurred. The client answers, "Three days ago." Which action should the PN implement first?
Administer a prescribed PRN stool softener
Determine the client's usual bowel patern
Encourage the client to ambulate more frequently
Recommend increasing high-fiber foods daily
The Correct Answer is B
- A bowel patern is the frequency, consistency, and appearance of a person's bowel movements. A normal bowel patern is what's normal for each person, and it can vary depending on factors such as diet, age, physical activity, and health conditions.
- A focused gastrointestinal system assessment includes collecting subjective data about the patient's history of gastrointestinal disease, signs and symptoms of gastrointestinal problems, diet and nutrition, and bowel patern. It also includes inspecting and auscultating the abdomen for any abnormalities³.
- When a client reports having a bowel movement three days ago, the first action that the practical nurse should implement is to determine the client's usual bowel patern. This will help to evaluate if the client is experiencing constipation or if this is their normal frequency. It will also help to identify any changes or risk factors that may affect the client's bowel function.
Therefore, option B is the correct answer, while options A, C, and D are incorrect.
Option A is incorrect because administering a stool softener without assessing the client's bowel patern may not be appropriate or effective.
Option C is incorrect because encouraging ambulation may help to stimulate bowel activity, but it is not the first action to take.
Option D is incorrect because recommending dietary changes may be helpful for preventing or treating constipation, but it is not the first action to take.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Concerns about parenting. While concerns about parenting are important to address during prenatal care, the initial visit focuses on gathering essential information and providing education related to pregnancy and childbirth. Knowledge about labor and delivery is crucial for the client to understand the process and make informed decisions.
Choice B rationale:
Cultural practices related to childbearing. Cultural practices related to childbearing are also essential topics to discuss during prenatal care, but they may not be the highest priority at the initial visit. Understanding the client's cultural background and beliefs is important, but providing information about pregnancy and childbirth should take precedence during the first prenatal visit.
Choice C rationale:
Complications associated with childbirth. Discussing complications associated with childbirth is important, but it may be overwhelming for a client during the initial prenatal visit. The primary focus should be on providing basic information and addressing immediate questions and concerns, with more in-depth discussions about complications occurring in subsequent visits.
Choice D rationale:
Knowledge about labor and delivery. This is the correct choice because the initial prenatal visit should include education about pregnancy, labor, and delivery. Providing the client with essential knowledge about what to expect during labor and delivery empowers her to make informed decisions and plan for her childbirth experience.
Correct Answer is A
Explanation
Choice A rationale:
Supplemental oxygen is given to the patient to prevent hypoxia and tissue damage due to pneumonia. Pneumonia is an infection that inflames the air sacs in one or both lungs, which may fill with fluid or pus, causing cough with phlegm or pus, fever, chills, and difficulty breathing. Hypoxia occurs when the body or a region of the body is deprived of adequate oxygen supply at the tissue level. It can cause serious damage to your heart, brain, and other organs. Hence, supplemental oxygen is administered to ensure that the patient’s tissues receive adequate oxygen.
Choice B rationale:
While supplemental oxygen can indirectly help lower blood pressure by improving oxygen supply and reducing strain on the heart, it is not primarily used for this purpose. Enalapril, which the patient is already taking, is an angiotensin-converting enzyme (ACE) inhibitor that is commonly used to lower blood pressure and reduce the workload of the heart.
Choice C rationale:
Supplemental oxygen does increase the oxygen saturation and improve respiratory function. However, this is a more general rationale for providing supplemental oxygen and not specific to this patient’s condition of pneumonia.
Choice D rationale:
Supplemental oxygen does not directly dilate the bronchioles or decrease inflammation in the lungs. Medications such as bronchodilators and corticosteroids are typically used for these purposes. In this case, supplemental oxygen is being used to prevent hypoxia and tissue damage due to pneumonia.
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