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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

The client takes ibuprofen for headaches. NSAIDs such as ibuprofen can cause gastrointestinal bleeding, which can result in a false positive result on a fecal occult blood test.

Option A is incorrect because breast cancer is not associated with false-positive fecal occult blood results.

Option C is incorrect because citrus juice does not affect the fecal occult blood test.

Option D is incorrect because a hemorrhoidectomy is not associated with false-positive fecal occult blood results.

Reasons why the other options are not answered:

Option A: Breast cancer is not associated with false-positive fecal occult blood results.

Option C: Citrus juice does not affect the fecal occult blood test.

Option D: A hemorrhoidectomy is not associated with false-positive fecal occult blood results.

A. Recent exposure to tuberculosis B. History of generalized anxiety disorder C. Reports periodic migraine headaches D. Experiences nocturia E. Experiences nocturia

Correct Answer is A

Explanation

Recent exposure to tuberculosis. This is the priority data that the nurse should address as it puts other clients and hospital staff at risk of contracting tuberculosis. Options B, C, and D are not urgent and can be addressed after addressing option A.

Reasons why the other options are not answers:

Option B: A history of generalized anxiety disorder is not an urgent issue that requires the nurse's immediate attention.

Option C: Reports periodic migraine headaches are not an urgent issue that requires the nurse's immediate attention.

Option D: Experiencing nocturia is not an urgent issue that requires the nurse's immediate attention.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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