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 B
Explanation
The correct answer is choice B: Store opened insulin vials at room temperature for up to 4 weeks.
Choice B rationale: Opened insulin vials can be stored at room temperature (59°F to 86°F or 15°C to 30°C) for up to 4 weeks. After this period, the insulin may lose potency, and a new vial should be used.
Choice A rationale: Regular insulin is short-acting, and its peak effect occurs 2 to 3 hours after administration. Eating a snack 6 hours after insulin administration may not be necessary as the insulin would have already reached its peak effect, and blood glucose levels should be monitored accordingly.
Choice C rationale: Warming the insulin vial to dissolve crystals is not recommended. Insulin should be inspected before use, and if crystals or clumps are present, it should be discarded as this could indicate that the insulin has lost its effectiveness.
Choice D rationale: Unopened insulin vials should be stored in the refrigerator (36°F to 46°F or 2°C to 8°C) and should not be frozen. Freezing can cause insulin to lose potency or become ineffective. Once opened, insulin vials can be stored at room temperature for up to 4 weeks, as mentioned in choice B.
Correct Answer is A,C,B
Explanation
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