A 67-year-old patient tells the nurse, “l have problems with constipation now that I am older, so I use a suppository every morning” The most appropriate nursing action at this time is to

encourage the patient to drink at least 3000 ml of ﬂuid a day.

suggest that the patient increase dietary intake of foods that are high in fiber.

inform the patient that a daily bowel movement is not necessary.

perform a focused nursing assessment to identify risk factors for constipation.

Answer and Explanation

The Correct Answer is D

Although increasing ﬂuid intake and fiber intake are important interventions for preventing constipation, it is important to first assess the patient's current situation and risk factors for constipation. Additionally, while a daily bowel movement is not necessary for everyone, it is important to understand the patient's usual bowel habits and whether or not their current regimen is eﬀective for them. Therefore, the nurse should perform a focused nursing assessment to identify the patient's risk factors for constipation and evaluate their current bowel regimen before providing specific interventions or recommendations.

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Correct Answer is B

Explanation

Counting sponges, needles, and surgical instruments is an intraoperative activity that is specific to the circulating function of the perioperative nurse. The nurse is responsible for maintaining an accurate count of all surgical items to prevent leaving any foreign objects inside the patient after the surgery. This is a crucial task to ensure patient safety and prevent any potential complications that may arise from such errors.

Option a. admitting, identifying, and assessing the patient, is a preoperative function that is usually performed by the preoperative nurse.

Option c. passing instruments to the surgeon and assistants, is a scrub nurse function that requires knowledge of the surgical procedure and a sterile technique.

Option d. preparing the instrument table and sterile equipment is also a scrub nurse function that requires expertise in sterile technique, knowledge of surgical procedures, and the ability to maintain a sterile environment.

A. Excess ﬂuid volume related to intake greater than output. B. Risk for impaired skin integrity related to generalized edema. C. Activity intolerance related to muscle cramps and weakness. D. Insomnia related to waking at night to void.

Correct Answer is A

Explanation

Excess ﬂuid volume related to intake greater than output would be the most appropriate nursing diagnosis for a patient with symptoms of DI (diabetes insipidus). This condition results in excessive urine output and, as a consequence, can lead to dehydration and electrolyte imbalances. Therefore, monitoring and managing ﬂuid volume is a priority for patients with DI.

Risk for impaired skin integrity related to generalized edema is more commonly associated with conditions that cause ﬂuid retention such as heart failure, liver failure, or kidney disease, rather than DI.

Activity intolerance related to muscle cramps and weakness is a possible nursing diagnosis for patients with conditions that aﬀect muscle function, such as muscular dystrophy or multiple sclerosis, but not specifically for DI.

Insomnia related to waking at night to void is more commonly associated with urinary frequency or nocturia due to conditions such as urinary tract infections or benign prostatic hyperplasia, but not specifically for DI.

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A 67-year-old patient tells the nurse, “l have problems with constipation now that I am older, so I use a suppository every morning” The most appropriate nursing action at this time is to

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

One of the intraoperative activities that are performed by the perioperative nurse and are specific to the circulating function is:

Correct Answer is B

Explanation

The nurse is creating the care plan for a patient with symptoms of DI who was admited to the hospital for evaluation and treatment of the condition. An appropriate nursing diagnosis for the patient is:

Correct Answer is A

Explanation

A patient who is hospitalized with abdominal pain and watery, incontinent diarrhea is diagnosed with Clostridium difficile. In planning care for the patient, the nurse will:

The physical environment and traffic control measures of the operating room are designed primarily to:

A 67-year-old patient tells the nurse, “l have problems with constipation now that I am older, so I use a suppository every morning” The most appropriate nursing action at this time is to

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