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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

The correct answer is B. Decreased deep tendon reflexes. Hyperkalemia can lead to muscle weakness and decreased reflexes, which is a common manifestation in patients with chronic kidney disease.

Choice A reason:

Wheezing is typically associated with respiratory conditions such as asthma or chronic obstructive pulmonary disease (COPD), not hyperkalemia. Hyperkalemia affects the muscular function and cardiac conduction rather than causing respiratory symptoms.

Choice B reason:

Decreased deep tendon reflexes occur due to the effect of hyperkalemia on the neuromuscular junction and muscle excitability. In hyperkalemia, the resting membrane potential of muscle cells is less negative, which makes them less responsive to stimuli.

Choice C reason:

Hypoactive bowel sounds are generally associated with gastrointestinal issues and are not a direct manifestation of hyperkalemia. While severe hyperkalemia can affect smooth muscle function, it is not typically characterized by changes in bowel sounds.

Choice D reason:

Cerebral edema is not a manifestation of hyperkalemia. It is usually caused by traumatic brain injury, infections, or other neurological conditions. Hyperkalemia primarily affects muscular function and cardiac conduction.

Normal serum potassium levels range from about 3.5 to 5.0 mmol/L. Hyperkalemia is defined as serum potassium levels above 5.0 mmol/L.

A. Tachycardia B. Weight loss C. Hypotension D. Diaphoresis

Correct Answer is A

Explanation

Choice A reason: Tachycardia is a sign of circulatory overload. Circulatory overload is a condition where the blood volume or rate of infusion is too high for the client's cardiovascular system. This causes the heart to beat faster and harder to pump the excess fluid, resulting in a high heart rate, or tachycardia.

Choice B reason: Weight loss is not a sign of circulatory overload. Weight loss is a condition where the body loses more calories than it consumes, resulting in a decrease in body mass. Weight loss can be caused by various factors, such as diet, exercise, illness, or medication. Weight gain, not weight loss, is a sign of circulatory overload, as the excess fluid accumulates in the body.

Choice C reason: Hypotension is not a sign of circulatory overload. Hypotension is a condition where the blood pressure is too low, which can impair the blood flow to the vital organs. Hypotension can be caused by various factors, such as dehydration, bleeding, shock, or medication. Hypertension, not hypotension, is a sign of circulatory overload, as the excess fluid increases the pressure in the blood vessels.

Choice D reason: Diaphoresis is not a sign of circulatory overload. Diaphoresis is a condition where the body sweats excessively, which can help to regulate the body temperature and eliminate toxins. Diaphoresis can be caused by various factors, such as fever, anxiety, exercise, or medication. Edema, not diaphoresis, is a sign of circulatory overload, as the excess fluid leaks into the interstitial spaces and causes swelling.

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A nurse is caring for an older adult client who has constipation. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a client who has chronic kidney disease. Which of the following findings is a manifestation of hyperkalemia?

Correct Answer is B

Explanation

A nurse is collecting data on a client who has circulatory overload. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is caring for a client who has nausea and is vomiting. The nurse should identify that the client is at risk for which of the following acid-base imbalances?

A nurse is collecting data on a client who has urinary retention. Which of the following findings should the nurse expect?

A nurse is caring for a client who has paraplegia and is on an intermittent urinary catheterization program. Which of the following findings indicates to the nurse the need to catheterize the client?

A nurse is collecting data on a client who has respiratory acidosis. Which of the following findings should the nurse expect?

A nurse is collecting data on a client who has diarrhea. Which of the following findings is a manifestation of hypokalemia?

A nurse is reinforcing teaching with a newly licensed nurse about adverse effects of medications. The nurse should include that which of the following medications can cause constipation?

A nurse is assisting with the care of a client who has respiratory alkalosis and is hyperventilating. Which of the following actions should the nurse take?

A nurse is assisting with teaching a class about pulmonary circulation. The nurse should include that blood flows from the heart to the lungs from the right ventricle starting from which of the following locations?