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. Schedule for IVP. B. Draw blood for blood urea nitrogen (BUN) and creatinine. C. Insert 16 French retention catheter. D. Administer lorazepam (Ativan) 0.5 mg.

Correct Answer is C

Explanation

The nurse should act on the order to insert a 16 French retention catheter first. The patient's markedly distended bladder and agitated and confused state suggest acute urinary retention, which can be relieved by inserting a catheter to drain the urine. This is a priority intervention as urinary retention can lead to serious complications such as bladder rupture, hydronephrosis, and renal failure. Once the catheter is inserted and the patient's bladder is drained, the healthcare provider can order further tests such as an IVP or blood tests to assess renal function. The order for lorazepam can be addressed after the catheter is inserted and the patient's urinary retention is addressed.

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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

A 98-year-old patient with benign prostatic hyperplasia has a markedly distended bladder and is agitated and confused. All the following orders are received from the emergency department health care provider. Which order should the nurse act on first?

Correct Answer is C

Explanation

The nurse is caring for a patient with hypothermia and ﬂuid volume excess. Which of the following would be included in the plan of care?

The nurse is admitting a patient who is nauseated and vomiting up blood-streaked ﬂuid with diagnosis of acute gastritis. When obtaining the admission health history, it will be most important for the nurse to ask the patient about:

Mr. D receives a daily injection of 70/30 NPH/regular insulin premix at 7:00 AM. The nurse expects that a hypoglycemic reaction is most likely to occur between:

A client has been taught to restrict dietary sodium. Which food selection by the client indicates to the nurse that teaching has been eﬀective?

A with acute Gl bleeding is receiving normal saline IV at a rate of 500 ml/hr. Which assessment data obtained by the nurse are most important to communicate immediately to the healthcare provider?

A patient with primary hyperparathyroidism has a serum calcium level of 14 mg/dl (3.5 mmol/L), phosphorus of 1.7 mg/dl (55 mmol/L), serum creatinine of 2.2 mg/dl (194 mmol/L). and high urine calcium. While the patient awaits surgery, the nurse should:

A patient is hospitalized with acute adrenal insufficiency. The nurse determines that the patient is responding favorably to treatment on finding: