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. Record a palpable systolic pressure of 90 mm Hg is premature because the nurse has not yet completed the process of determining the systolic blood pressure.

B. Inflate blood pressure cuff to 120 mm Hg is the correct action. The nurse should inflate the cuff 30 mm Hg above the point where the radial pulse disappears to ensure accurate measurement of the systolic blood pressure.

C. Release the manometer valve immediately would not allow the nurse to accurately determine the systolic blood pressure. The valve should be released slowly to palpate the return of the pulse.

D. Document the absence of the radial pulse is unnecessary because the disappearance of the pulse is a normal part of the procedure when obtaining a systolic blood pressure by palpation.

A. Dons sterile gloves when caring for clients with HIV. B. Uses sterile gloves when handling body fluids. C. Keeps a pair of gloves in uniform pocket. D. Puts on new gloves when entering a client's room.

Correct Answer is B

Explanation

A. Dons sterile gloves when caring for clients with HIV is incorrect. HIV is transmitted through specific body fluids such as blood, semen, and vaginal fluids, but sterile gloves are not required for routine care unless there is a risk of exposure to these fluids. Standard precautions are used for all clients, regardless of their diagnosis.

B. Uses sterile gloves when handling body fluids is correct. Sterile gloves are used in situations where there is a high risk of contamination, such as when handling body fluids that may contain infectious agents, or during invasive procedures.

C. Keeps a pair of gloves in uniform pocket is incorrect. Gloves should not be stored in pockets as this may compromise their sterility or cleanliness. Gloves should be stored in a clean, dry place.

D. Puts on new gloves when entering a client's room is incorrect. Gloves should be worn when necessary, such as when there is a risk of contact with body fluids or contaminated surfaces. They should not be put on automatically without assessing the situation.

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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 is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?

Correct Answer is B

Explanation

The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?

Correct Answer is B

Explanation

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