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
The correct answer is choice A, "Take a shower rather than a tub bath." This is a safety precaution to prevent infection . Choice B is incorrect because clients are encouraged to walk around after surgery to prevent blood clots. Choice C is incorrect because douching after surgery can increase the risk of infection. Choice D is incorrect because bright red vaginal bleeding after surgery warrants a followup with a healthcare provider. Choice B is not correct because clients are encouraged to walk around after surgery to prevent blood clots. Choice C is not correct because douching after surgery can increase the risk of infection. Choice D is not correct because bright red vaginal bleeding after surgery warrants a followup.
Correct Answer is D
Explanation
knee-chest. During sigmoidoscopy, the client should lie on their left side with their right knee flexed slightly. The nurse should then position the client in the knee-chest (Sims) position, where the client leans forward with bent knees and support the chest and forearms on the table or a pillow. This allows better visualization and access to the rectal area for the sigmoidoscopy procedure.
An explanation for incorrect choices:
A. Orthopneic position is upright sitting with arms and elbows resting on a table or on a pillow, which helps clients who have difficulty breathing; it is not suitable for sigmoidoscopy.
B. Trendelenburg position
is supine with the head lower than the feet, which can cause blood flow to the head and increased intracranial pressure; it is not suitable for sigmoidoscopy.
C. Prone position is lying face down, which is not suitable for sigmoidoscopy.
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