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 D
Explanation
Answer is: d. Reposition the client.
Explanation: Repositioning the client can help alleviate pain by redistributing pressure and promoting comfort. Since the client's pain level is relatively low (2 on a scale of 0 to 10), this non-pharmacological intervention is an appropriate initial action.
Choice a. is wrong because maintaining the client on bed rest is not an appropriate action for a pain level of 2. Instead, the nurse should encourage the client to mobilize and perform appropriate exercises to prevent complications related to immobility.
Choice b. is wrong because applying a warm, moist compress to the incision area might not be the best action for a client who is 24 hours postoperative, as it could increase the risk of infection and cause discomfort. Cold compresses are often used in the initial postoperative period to reduce swelling and promote comfort.
Choice c. is wrong because administering an additional dose of pain medication is not necessary at this point, as the client's pain level is relatively low. The nurse should consider non-pharmacological interventions first and reassess the client's pain level to determine the need for further pain relief.
Correct Answer is C
Explanation
The correct answer is choice C. Implement droplet precautions. Streptococcal pharyngitis is a highly contagious infection caused by group A beta-hemolytic streptococcus. Droplet precautions are the appropriate precautionary measures to prevent the spread of the infection. This includes placing the client in a private room or with a client with the same infection, wearing a mask or respirator, and using proper hand hygiene. Option A is incorrect because negative airflow rooms are not required for clients with streptococcal pharyngitis. Option B is incorrect because throat cultures should be obtained before the initial dose of antibiotics. Option D is incorrect because fluid restriction is not a necessary intervention for clients with streptococcal pharyngitis.
Option A - Negative airflow rooms are used for airborne illnesses like tuberculosis.
Option B - Throat culture should be obtained before the initial dose of antibiotics.
Option D - Fluid restriction is not a necessary intervention for clients with streptococcal pharyngitis.
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