A nurse is caring for a client and is concerned that the client might have a fecal impaction. Which of the following is the most important question for the nurse to ask?
"What types of foods have you been eating?”
"Are you using stool softeners or laxatives?”
"Have you been passing gas?”
"Have you had small liquid stools?”
The Correct Answer is D
The correct answer is choice d. “Have you had small liquid stools?”
Choice A rationale:
While knowing the types of foods the client has been eating can provide insight into dietary habits that may contribute to constipation, it is not the most direct question to identify a fecal impaction.
Choice B rationale:
Asking about the use of stool softeners or laxatives is relevant to understanding the client’s bowel management, but it does not directly indicate the presence of a fecal impaction.
Choice C rationale:
Passing gas can indicate that there is some bowel movement, but it does not confirm or rule out a fecal impaction.
Choice D rationale:
Small liquid stools can be a sign of fecal impaction, as liquid stool may leak around the impacted mass. This makes it the most important question to ask when suspecting a fecal impaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B: "Please don't tell my doctor, but I am taking my partner's oxycodone."
Choice B rationale:
This statement presents an ethical dilemma as it reveals the client's engagement in potentially harmful and illegal behavior – taking a controlled substance prescribed for someone else. The nurse must balance the duty to respect the client's confidentiality with the responsibility to address potential harm to the client and others involved.
Choice A rationale:
"I might file a lawsuit because of how my surgery went" does not present an ethical dilemma, but rather a legal concern. While the nurse should listen to the client's complaints and provide appropriate support, this statement is more related to the client's dissatisfaction with their medical care.
Choice C rationale:
"Please don't get me out of bed this morning, It hurts too much" reflects a client's pain management request. While pain management is important, this statement doesn't raise an ethical dilemma on its own. It's within the scope of care to address pain and comfort concerns.
Choice D rationale:
"I don't want to take my medicine. It makes me sick to my stomach" highlights a client's concern about medication side effects. While addressing medication concerns is essential, this statement doesn't inherently pose an ethical dilemma.
Correct Answer is C
Explanation
The correct answer is choice C: "I should remove constrictive clothing prior to measuring my blood pressure."
Choice A rationale:
"I will wait 15 minutes after drinking coffee to measure my blood pressure." Caffeine intake can temporarily elevate blood pressure, so waiting 15 minutes after drinking coffee is a good practice. However, this is not the most relevant instruction to ensure accurate blood pressure measurement.
Choice B rationale:
"I will measure my blood pressure while my arm is elevated above my heart." Measuring blood pressure with the arm elevated above the heart can result in artificially low readings. The arm should be supported at heart level for accurate results. Therefore, this statement is incorrect.
Choice C rationale:
"I should remove constrictive clothing prior to measuring my blood pressure." This is the correct choice. Constrictive clothing can impact blood flow and give inaccurate readings. Removing tight clothing ensures the blood pressure cuff can be appropriately placed and that the measurements are reliable.
Choice D rationale:
"I should measure my blood pressure immediately after eating breakfast." Blood pressure can be affected by food intake, so it's recommended to wait at least 30 minutes after eating before measuring blood pressure. This choice is not accurate as immediate post-breakfast measurements may not provide accurate results.
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