A client tells the nurse that he takes laxatives every day but is still constipated. The nurse's response is based on which reasoning?

If laxatives are not effective, the client should begin to use enemas.

Habitual laxative use is the most common cause of chronic constipation.

A laxative that works by a different method should be used.

Chronic constipation is nothing to be concerned about.

Answer and Explanation

The Correct Answer is C

Choice A rationale: Using enemas should not be the first response to constipation. There are various types of laxatives with different mechanisms of action that can be tried before resorting to enemas.
Choice B rationale: Habitual laxative use can contribute to chronic constipation, but it is not the most common cause. It is essential to identify and address the underlying cause of constipation.
Choice C rationale: If laxatives are not effective, trying a laxative with a different mechanism of action may be more successful in relieving constipation.
Choice D rationale: Chronic constipation should be assessed and addressed, as it can lead to complications and should not be dismissed as insignificant.

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Correct Answer is A

Explanation

Choice A rationale: Voiding and discarding the urine is the first step in a 24-hour urine collection to ensure that the collection starts with a fresh specimen.
Choice B rationale: Adding the first voiding to the specimen is not the correct initial step.
Choice C rationale: Keeping the urine warm during collection is important, but it is not the first step in the process.
Choice D rationale: Beginning the collection at a specific time is part of the process but not the initial step.

A. The patient may have paralytic ileus that could last 3-5 days B. It is normal for all post-op patients not to have bowel sounds C. The absence of bowel sounds is an abnormal finding D. Document absent bowel sounds and notify the physician

Correct Answer is A

Explanation

Choice A rationale: The absence of bowel sounds on post-operative day 2 may indicate paralytic ileus, which is a temporary impairment of bowel motility. Paralytic ileus can last for 3-5 days postoperatively and is considered a normal response to surgery.
Choice B rationale: It is not normal for all post-op patients to have absent bowel sounds on day 2. Bowel sounds should typically return within the first 24 hours after surgery.
Choice C rationale: The absence of bowel sounds can be a normal finding in the immediate postoperative period, especially within the first 24 hours. However, it becomes abnormal if prolonged.
Choice D rationale: Documenting absent bowel sounds is appropriate, but notifying the physician should be based on the overall clinical picture and other symptoms.

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A client tells the nurse that he takes laxatives every day but is still constipated. The nurse's response is based on which reasoning?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is initiating a 24-hour urine collection for a client at home. What will be the first thing the nurse will ask the client to do at the beginning of the specimen collection?

Correct Answer is A

Explanation

A nurse is assessing bowel sounds on post-operative day 2 abdominal surgery patients. He does not hear bowel sounds. What should the nurse conclude about his findings?

Correct Answer is A

Explanation

A nurse assessing a client notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. The nurse should associate these findings with which of the following types of urinary incontinence?

A nurse is implementing a bowel training program for a client. For the program to be effective, the nurse should take the client to the toilet at which of the following times?

The nurse uses gait belts when assisting clients to ambulate. Which client would be a likely candidate for this assistive device?

A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take?

A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full-thickness wound with jagged edges and muscle tissue visible after a biking accident. The nurse should document this as which of the following types of wounds?

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When measuring the size, depth, and wound tunneling of a client's stage 4 pressure injury, what action should the nurse perform first?

A nurse is completing a chart audit and finds the following wound documented as a Stage I Pressure Ulcer. The nurse recognizes this is incorrect. How should the wound have been classified?