A nurse is assisting in the plan of care for a client who has constipation after receiving opioid medication for incisional pain. Which of the following actions should the nurse take first?
Auscultate the client's abdomen for bowel sounds.
Provide the client privacy with a set time to defecate.
Administer a fiber-based laxative to the client.
Encourage the client to increase oral intake of fluids.
The Correct Answer is A
The correct answer is choice A. Auscultate the client's abdomen for bowel sounds. This is the first action the nurse should take because it provides information about the client's bowel motility and function. Opioid medications can decrease bowel motility and cause constipation. The nurse should assess the client's abdomen before implementing any interventions.
- Choice B is not correct because providing privacy and a set time to defecate is a nonpharmacological intervention that can help prevent constipation, but it is not the first action the nurse should take.
- Choice C is not correct because administering a fiber-based laxative is a pharmacological intervention that can help treat constipation, but it is not the first action the nurse should take. The nurse should also consider the client's fluid intake and preference before giving a laxative.
- Choice D is not correct because encouraging the client to increase oral intake of fluids is a nonpharmacological intervention that can help prevent constipation, but it is not the first action the nurse should take. The nurse should also consider the client's fluid balance and medical condition before giving fluids.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A potassium level of 3.2 mEq/L indicates hypokalemia, which can lead to muscle weakness. Difficulty swallowing, hyperreflexia, and diarrhoea are not typical signs of hypokalemia.
Other choices are not correct because:
B. Difficulty swallowing: Is not a typical sign of hypokalemia.
C. Hyperreflexia: Is not a typical sign of hypokalemia.
D. Diarrhea: Is not a typical sign of hypokalemia.
Correct Answer is A
Explanation
The nurse should instruct the client to avoid taking medications for erectile dysfunction, such as sildenafil, within 24 hours of taking nitroglycerin due to the risk of severe hypotension.
Reasons why the other options are not answers:
Option B: Metformin is not contraindicated with nitroglycerin.
Option C: Omeprazole is not contraindicated with nitroglycerin.
Option D: Atorvastatin is not contraindicated with nitroglycerin.
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