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

Choice A reason: Rigid abdomen is not a sign of diarrhea, but rather a sign of peritonitis, which is an inflammation of the abdominal lining. Peritonitis can be caused by a perforated ulcer, appendicitis, or diverticulitis.

Choice B reason: Dehydration is a sign of diarrhea, as it indicates a loss of fluid and electrolytes from the body. Dehydration can cause symptoms such as dry mouth, thirst, decreased urine output, sunken eyes, and low blood pressure.

Choice C reason: Hypothermia is not a sign of diarrhea, but rather a sign of low body temperature. Hypothermia can be caused by exposure to cold, shock, or infection.

Choice D reason: Decreased bowel sounds are not a sign of diarrhea, but rather a sign of ileus, which is a lack of intestinal activity. Ileus can be caused by surgery, medication, or obstruction.

A. Obtain a prescription to administer insulin. B. Obtain a prescription for supplemental oxygen. C. Obtain a prescription to check the client's glucose level. D. Obtain a prescription to administer intravenous fluids.

Correct Answer is B

Explanation

Choice A reason: Obtaining a prescription to administer insulin is an important action for the nurse to take, as insulin helps to lower the blood glucose level and reverse the metabolic acidosis caused by diabetic ketoacidosis. However, it is not the first action the nurse should take, as the client's hypoxia is a more urgent problem that requires immediate intervention.

Choice B reason: Obtaining a prescription for supplemental oxygen is the first action the nurse should take, as hypoxia is a life-threatening condition that can lead to tissue damage, organ failure, and death. The nurse should provide oxygen therapy to improve the client's oxygen saturation and prevent further complications.

Choice C reason: Obtaining a prescription to check the client's glucose level is a necessary action for the nurse to take, as glucose monitoring helps to evaluate the client's response to insulin therapy and guide further interventions. However, it is not the first action the nurse should take, as the client's hypoxia is a more urgent problem that requires immediate intervention.

Choice D reason: Obtaining a prescription to administer intravenous fluids is a beneficial action for the nurse to take, as fluid replacement helps to correct the dehydration, electrolyte imbalance, and hypotension caused by diabetic ketoacidosis. However, it is not the first action the nurse should take, as the client's hypoxia is a more urgent problem that requires immediate intervention.

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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 had diarrhea for several days. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is assisting in the care of a client who has diabetic ketoacidosis and hypoxia. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A charge nurse in a long-term care facility is observing another nurse who is inserting an indwelling urinary catheter into a female client. Which of the following actions by the nurse should prompt the charge nurse to intervene?

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

A nurse is preparing to remove a client's urinary catheter. After performing hand hygiene, which of the following actions should the nurse take?

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

A nurse is reinforcing teaching with a client about foods and beverages that can cause diarrhea. Which of the following should the nurse include in the teaching?

A nurse is caring for a client who has metabolic alkalosis. Which of the following actions should the nurse take first?

A nurse is caring for a client who has pneumonia and has been receiving oxygen therapy for several days. When collecting data from the client, the nurse should identify which of the following findings as an indication of an adverse effect of oxygen therapy?

A nurse is caring for a client who reports constipation. The provider has prescribed an enema. Identify the sequence of steps the nurse should take to administer the enema. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)