A nurse is caring for an older adult client who has constipation. Which of the following actions should the nurse take?
Request that the provider prescribe a stool softener.
Add fluid and fiber to the diet.
Promote active range-of-motion activities.
Avoid gas-producing foods.
The Correct Answer is B
Choice A reason: Requesting that the provider prescribe a stool softener is not the best action for the nurse to take, as it may cause dependency, dehydration, or electrolyte imbalance. The nurse should try non-pharmacological interventions first, such as increasing fluid and fiber intake, promoting physical activity, and establishing a regular bowel routine.
Choice B reason: Adding fluid and fiber to the diet is the best action for the nurse to take, as it helps to soften the stool, increase the bulk, and stimulate peristalsis. The nurse should encourage the client to drink at least 2 liters of water per day and eat foods rich in fiber, such as fruits, vegetables, and whole grains.
Choice C reason: Promoting active range-of-motion activities is a good action for the nurse to take, as it helps to improve circulation, muscle tone, and bowel motility. The nurse should assist the client to perform exercises that are appropriate for their level of mobility and endurance.
Choice D reason: Avoiding gas-producing foods is not a necessary action for the nurse to take, as it does not directly affect constipation. Gas-producing foods, such as beans, cabbage, and broccoli, may cause bloating and discomfort, but they do not cause or worsen constipation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Bacteria are not detected by the stool guaiac test. The stool guaiac test is a chemical test that reacts with hemoglobin, a protein found in red blood cells. Bacteria are microorganisms that do not contain hemoglobin.
Choice B reason: Fat is not detected by the stool guaiac test. The stool guaiac test is a chemical test that reacts with hemoglobin, a protein found in red blood cells. Fat is a lipid that does not contain hemoglobin.
Choice C reason: Parasites are not detected by the stool guaiac test. The stool guaiac test is a chemical test that reacts with hemoglobin, a protein found in red blood cells. Parasites are organisms that live in or on another host and do not contain hemoglobin.
Choice D reason: Blood is detected by the stool guaiac test. The stool guaiac test is a chemical test that reacts with hemoglobin, a protein found in red blood cells. Blood can indicate bleeding in the gastrointestinal tract, which can be caused by various conditions such as ulcers, polyps, or cancer.
Correct Answer is D
Explanation
Choice A reason: Encourages oral fluid intake during waking hours is not an action that the nurse should intervene. Encouraging oral fluid intake during waking hours is a part of a bladder-training program, as it helps to maintain adequate hydration and prevent urinary tract infections. The nurse should instruct the AP to limit the client's fluid intake before bedtime, as it may cause nocturia and disrupt the bladder-training schedule.
Choice B reason: Assists the client to the bathroom every 2 hr is not an action that the nurse should intervene. Assisting the client to the bathroom every 2 hr is a part of a bladder-training program, as it helps to establish a regular pattern of voiding and reduce the risk of incontinence. The nurse should instruct the AP to gradually increase the interval between bathroom visits, as the client's bladder capacity and control improve.
Choice C reason: Offers the opportunity to urinate 15 min prior to bathing is not an action that the nurse should intervene. Offering the opportunity to urinate 15 min prior to bathing is a part of a bladder-training program, as it helps to prevent the stimulation of the micturition reflex by warm water and reduce the risk of accidental voiding. The nurse should instruct the AP to avoid giving the client diuretics, caffeine, or alcohol, as they may increase the urine output and frequency.
Choice D reason: Instructs the client to urinate whenever the urge occurs is an action that the nurse should intervene. Instructing the client to urinate whenever the urge occurs is not a part of a bladder-training program, as it does not help to improve the bladder function and may worsen the urge incontinence. The nurse should instruct the AP to teach the client some techniques to suppress the urge, such as pelvic floor exercises, deep breathing, or distraction.
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