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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Red streaks along the incision. This is a possible sign of infection and should be reported to the healthcare provider. A temperature of 37.2°C (99°F) is within the normal range and does not require reporting. Serosanguineous drainage at the incision site is normal within the first few days postoperatively. Hypoactive bowel sounds in all four quadrants can indicate ileus, which is a possible complication following abdominal surgery, but it is not an immediate concern and can be monitored unless other symptoms arise.
Choice A: A temperature of 37.2°C (99°F) is within the normal range and does not require reporting.
Choice B: Serosanguineous drainage at the incision site is normal within the first few days postoperatively.
Choice D: Hypoactive bowel sounds in all four quadrants can indicate ileus, which is a possible complication following abdominal surgery, but it is not an immediate concern and can be monitored unless other symptoms arise.
Correct Answer is B
Explanation
BUN 40 mg/dL. Elevated BUN levels can indicate impaired kidney function, which can be a potential adverse effect of long-term NSAID therapy.
Reasons why the other options are not answers:
Option A: Total bilirubin 0.8 mg/dL is a normal value and does not require reporting to the provider.
Option C: PaO2 90 mm Hg is within the normal range and does not require reporting to the provider.
Option D: Hematocrit 45% is within the normal range and does not require reporting to the provider.
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