A nurse is caring for a 9-year-old child at a clinic.

Exhibits

The nurse should determine that the assessment findings are consistent with which of the following conditions?
For each potential condition, click to specify if the assessment findings are consistent with a sprain, a fracture, or a dislocation. Each finding may support more than 1 condition.

Rationale:
A. "I will take a bulk-forming laxative every day.": While bulk-forming laxatives can help manage constipation, taking them without adequate fluid intake can worsen constipation or cause bowel obstruction. Education should emphasize combining fiber with sufficient fluids.

B. "I will avoid strenuous exercise.": Regular physical activity actually promotes intestinal motility and helps prevent opioid-induced constipation. Avoiding exercise would counteract this preventive strategy.

C. "I will increase my intake of high-fiber foods.": Consuming high-fiber foods, such as fruits, vegetables, and whole grains, adds bulk to stool and promotes regular bowel movements. This is a key dietary intervention for preventing constipation in clients taking opioids like oxycodone.

D. "I will limit my fluid intake to 1 liter per day.": Limiting fluids can exacerbate constipation because hydration is necessary to soften stool and support normal bowel function. Clients should maintain adequate fluid intake alongside increased dietary fiber.

Rationale:
A. Ensure the medication is administered within 3 hr of the scheduled time: Medications should typically be administered within 30 minutes before or after the scheduled time, not within 3 hours. Administering too early or too late can reduce therapeutic effectiveness or cause harm, depending on the medication type.

B. Use two identifiers to verify the client’s identity: Verifying identity with two identifiers—such as name and date of birth—ensures the right client receives the right medication. This practice aligns with the “five rights” of medication administration and is a critical step in preventing medication errors.

C. Document administration of the client’s routine medications at the beginning of the shift: Documentation should occur immediately after medication administration, not beforehand. Charting in advance increases the risk of errors and creates false records if the medication is delayed or omitted.

D. Check the label of the medication twice prior to administration: The nurse must check the medication label three times—when removing it from storage, before preparing it, and immediately before administration. Checking only twice does not meet safety standards.