A client on a mechanical soft diet is experiencing constipation and asks the nurse for a glass of prune juice. After auscultating decreased bowel sounds, which action should the nurse implement?

Restrict oral fluid intake.

Offer to warm the prune juice.

Advance to a regular diet.

Initiate bowel training protocol.

Answer and Explanation

The Correct Answer is D

A. Restrict oral fluid intake is not appropriate in this situation. Decreased bowel sounds and constipation may indicate a need for hydration, not restriction of fluids. Fluids are essential to help prevent and alleviate constipation.

B. Offer to warm the prune juice may be helpful in some cases to encourage the client to drink, but it does not address the underlying issue of constipation and decreased bowel sounds. A more comprehensive intervention, such as bowel training, is needed.

C. Advance to a regular diet may not be appropriate without assessing the client's tolerance for additional food types. The client is on a mechanical soft diet, which may already be sufficient. Advancing to a regular diet could potentially exacerbate the constipation.

D. Initiate bowel training protocol is the most appropriate action. Bowel training is designed to help manage constipation and promote regular bowel movements. This may include dietary adjustments, increased fluid intake, and other measures such as scheduled toileting.

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Correct Answer is B

Explanation

A. Capillary refill time is 2 seconds is within the normal range and is unlikely to interfere with the pulse oximeter reading.

B. 2+ edema of fingers and hands most likely contributes to the low oxygen saturation reading. Edema can impair the accuracy of a pulse oximeter by affecting the transmission of light through the tissues, leading to erroneous readings.

C. Blood pressure is 142/88 mm Hg is mildly elevated but does not directly affect the pulse oximeter's ability to measure oxygen saturation.

D. Radial pulse volume is 3+ indicates a strong pulse and does not interfere with the functionality of the pulse oximeter.

A. Ensure the client's environment is properly cleaned and disinfected. B. Reapply sterile non-adhesive dressing. C. Initiate contact precautions. D. Teach family members how to prevent transmission of infection.

Correct Answer is C

Explanation

A. Ensure the client's environment is properly cleaned and disinfected is important, but the priority action is to prevent the spread of MRSA, which is highly contagious. Contact precautions should be initiated immediately to reduce the risk of transmission to others, including healthcare staff and visitors.

B. Reapply sterile non-adhesive dressing is necessary for wound care, but it is not the most important action in this scenario. Ensuring the appropriate precautions are taken to prevent the spread of MRSA is the priority.

C. Initiate contact precautions is the most important action. MRSA is a highly contagious bacterial infection that can spread easily through contact with contaminated surfaces or individuals. By initiating contact precautions, the nurse helps to protect other patients, staff, and visitors from exposure to MRSA.

D. Teach family members how to prevent transmission of infection is important but should be done after the immediate infection control measures, such as initiating contact precautions, have been implemented. Family education can occur once the proper isolation procedures are in place.

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A client on a mechanical soft diet is experiencing constipation and asks the nurse for a glass of prune juice. After auscultating decreased bowel sounds, which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

Correct Answer is B

Explanation

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA) laboratory result, which action is the most important for the nurse to take?

Correct Answer is C

Explanation

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