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 A

Explanation

GERD can increase the risk of aspiration (inhalation of stomach contents into the lungs), which can cause respiratory issues, including abnormal breath sounds. In these cases, monitoring of breath sounds may be more appropriate than monitoring of bowel sounds.

Bowel sounds are not typically monitored for GERD patients as GERD is a condition that aﬀects the esophagus and the stomach, not the intestines. GERD is caused by the reﬂux of stomach contents into the esophagus, which can cause symptoms such as heartburn and regurgitation.

Abdominal girth is not routinely monitored for GERD patients as it is not typically related to the condition. GERD is a disorder that aﬀects the esophagus and stomach and does not typically cause significant changes in abdominal size or girth. In rare cases, GERD can be complicated by a condition known as a para oesophageal hernia, which can cause a visible bulge in the abdomen. In these cases, monitoring of abdominal size and shape may be necessary.

The apical pulse is not routinely monitored for GERD patients as it is not directly related to the condition. GERD is a disorder that aﬀects the digestive system, specifically the esophagus and stomach and does not typically have an impact on heart rate or rhythm.

A. The patient's lungs have crackles audible to the midline. B. The patient's BP has increased to 142/94 mm Hg. C. The bowel sounds are very hyperactive in all four quadrants. D. The NG suction is returning coﬀee-ground material.

Correct Answer is D

Explanation

Coﬀee-ground material in the NG suction indicates that there is active bleeding in the upper gastrointestinal tract, which could be a life-threatening situation. This requires immediate medical attention and intervention to control the bleeding and stabilize the patient.

Options A, B, and C are also important assessment data, but they are not as urgent as option D in this scenario.

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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

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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