A nurse is contributing to the plan of care of a client who has a small bowel obstruction. Which of the following interventions should the nurse include?
Measure abdominal girth daily.
Provide bulk-forming agent.
Elevate the head of the bed.
Monitor intake and output every 8 hr.
The Correct Answer is A
A. Measure abdominal girth daily. Monitoring abdominal girth (often more than once daily if indicated) helps detect increasing distention that suggests worsening obstruction or bowel compromise.
B. Provide bulk-forming agent. Bulk-forming laxatives (fiber agents) are contraindicated in mechanical small bowel obstruction because they can worsen obstruction.
C. Elevate the head of the bed. Not a primary intervention specific to small bowel obstruction; head elevation may assist breathing but does not treat obstruction and can increase risk of aspiration if vomiting-positioning should be individualized.
D. Monitor intake and output every 8 hr. Inadequate frequency. I&O should be monitored more frequently (often hourly or every shift depending on severity) in small bowel obstruction to detect dehydration/electrolyte losses-every 8 hours is insufficient for most obstructed patients.
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Related Questions
Correct Answer is D
Explanation
A. Store the medication in the refrigerator:Sucralfate does not require refrigeration; standard storage at room temperature is appropriate.
B. Take the medication with an antacid:Antacids can interfere with sucralfate binding; they should not be taken at the same time (administer separately per provider/label).
C. Take as needed for pain relief:Sucralfate is a mucosal protectant taken on a schedule (usually before meals and at bedtime), not only PRN for pain.
D. Take the medication 1 hr before meals:Sucralfate is best taken about 1 hour before meals to form a protective barrier over the ulcer - this is the correct instruction.
Correct Answer is A
Explanation
A. Measure abdominal girth daily.Monitoring abdominal girth (often more than once daily if indicated) helps detect increasing distention that suggests worsening obstruction or bowel compromise.
B. Provide bulk-forming agent.Bulk-forming laxatives (fiber agents) are contraindicated in mechanical small bowel obstruction because they can worsen obstruction.
C. Elevate the head of the bed.Not a primary intervention specific to small bowel obstruction; head elevation may assist breathing but does not treat obstruction and can increase risk of aspiration if vomiting-positioning should be individualized.
D. Monitor intake and output every 8 hr.Inadequate frequency. I&O should be monitored more frequently (often hourly or every shift depending on severity) in small bowel obstruction to detect dehydration/electrolyte losses-every 8 hours is insufficient for most obstructed patients.
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