A nurse is caring for a client who is postoperative and requesting something to drink. The nurse reads the client's postoperative prescriptions, which include, "Clear liquids, advance diet as tolerated." Which of the following actions should the nurse take first?
Order a lunch tray for the client.
Offer the client apple juice.
Auscultate the client's abdomen.
Elevate the client's head of bed.
The Correct Answer is C
A. Order a lunch tray for the client. Before advancing the diet, it is important to assess the client's readiness, particularly bowel sounds.
B. Offer the client apple juice. Providing liquids is appropriate only after assessing the client's gastrointestinal function.
C. Auscultate the client's abdomen: This assessment checks for the return of bowel sounds and gastrointestinal function, indicating whether the client can tolerate clear liquids.
D. Elevate the client's head of bed. While positioning is important, the primary first step is to assess the client's gastrointestinal status
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Avoid gas-producing foods: Avoiding gas-producing foods may reduce bloating but does not directly address constipation.
B. Add fluid and fiber to the diet. Increasing fluid and fiber intake helps to soften stool and promote regular bowel movements.
C. Promote active range-of-motion activities: While physical activity can help with bowel movements, active range-of-motion activities alone are not sufficient to address constipation.
D. Request that the provider prescribe a stool softener: This may be helpful but is usually considered after dietary measures have been attempted.
Correct Answer is B
Explanation
A. Parasites: The stool guaiac test does not detect parasites; it is used to detect blood.
B. Blood: The stool guaiac test (or fecal occult blood test) detects hidden (occult) blood in the stool.
C. Bacteria: The stool guaiac test does not identify bacteria; stool cultures are used for that purpose.
D. Fat: The stool guaiac test does not measure fat content; a fecal fat test is used for detecting fat.
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