A nurse is providing care for an elderly patient who is experiencing constipation.
What action should the nurse take?

Request a prescription for a stool softener from the provider.

Incorporate more fluids and fiber into the patient’s diet.

Encourage the patient to engage in active range-of-motion exercises.

Advise the patient to avoid foods that cause gas.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Requesting a prescription for a stool softener from the provider could be a potential solution, but it’s not the first step. Medications should be considered when lifestyle modifications and dietary changes are not effective.

Choice B rationale:

Incorporating more fluids and fiber into the patient’s diet is the most appropriate action. Constipation in older adults can be caused by dehydration and not eating enough. Dietary fiber adds bulk to the diet and is capable of absorbing water, which helps to soften the stool and promote regular bowel movements. Therefore, increasing fluid and fiber intake is often the first step in managing constipation.

Choice C rationale:

Encouraging the patient to engage in active range-of-motion exercises might not directly alleviate constipation. While physical activity is generally beneficial for overall health, increased exercise does not improve symptoms of constipation in nursing home residents or older adults.

Choice D rationale:

Advising the patient to avoid foods that cause gas might help if the patient has bloating or gas, but it won’t necessarily address the issue of constipation. The focus should be on increasing fiber and fluid intake.

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Correct Answer is C

Explanation

The correct answer is choice C.

Choice A rationale:

The nurse applies the sterile drape after cleaning the perineal area. This is correct because the perineal area should be cleaned before applying the sterile drape. Applying the drape first could potentially introduce bacteria to the catheter during insertion, increasing the risk of a urinary tract infection.

Choice B rationale:

The nurse lubricates the indwelling urinary catheter. This is a correct procedure as it helps to minimize discomfort and trauma during catheter insertion.

Choice C rationale:

The nurse separates the patient’s labia with her dominant hand. This is also a correct procedure. The nurse should use her non-dominant hand to separate the labia and expose the urethral meatus, and then use her dominant hand to insert the catheter.

Choice D rationale:

The nurse provides perineal care prior to inserting the urinary catheter. This is a correct procedure. Providing perineal care before inserting a urinary catheter is important to reduce the risk of introducing bacteria into the urinary tract. It’s part of maintaining strict aseptic technique during insertion.

A. Dry skin B. Diarrhea C. Abdominal pain D. Hyperventilation E. Hyperventilation

Correct Answer is D

Explanation

Choice A rationale:

Dry skin is not typically associated with respiratory alkalosis. Respiratory alkalosis occurs when the levels of carbon dioxide and oxygen in the blood aren’t balanced, often due to hyperventilation. Dry skin is not listed as a common symptom of this condition.

Choice B rationale:

Diarrhea is not a common symptom of respiratory alkalosis. The condition is characterized by symptoms such as dizziness, numbness, confusion, and shortness of breath. Diarrhea is more commonly associated with gastrointestinal issues rather than respiratory conditions.

Choice C rationale:

Abdominal pain is not a typical symptom of respiratory alkalosis. The condition is usually caused by over-breathing

(hyperventilation) that occurs when you breathe very deeply or rapidly. Abdominal pain is not listed as a common symptom of this condition.

Choice D rationale:

Hyperventilation is typically the underlying cause of respiratory alkalosis. Hyperventilation, also known as overbreathing, occurs when someone breathes very deeply or rapidly. This can cause the levels of carbon dioxide in the blood to drop too low, leading to respiratory alkalosis. Therefore, a nurse assessing a client who has respiratory alkalosis should expect to find signs of hyperventilation.

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A nurse is providing care for an elderly patient who is experiencing constipation. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is C

Explanation

A nurse is assessing a client who has respiratory alkalosis. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a patient who reports constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)

A nurse is gathering data on a patient who is suffering from circulatory overload. What symptoms should the nurse anticipate?

A nurse is reinforcing teaching with a patient who reports constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)

A nurse is educating a patient who has an ileal conduit due to bladder cancer. Which statement from the patient suggests that further instruction is needed?

A nurse is caring for a patient with metabolic alkalosis. What actions should the nurse take?

A nurse is preparing to remove a patient’s urinary catheter. After performing hand hygiene, what should the nurse do next?

A nurse is caring for a patient with diabetic ketoacidosis and hypoxia. What is the first action the nurse should take?

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

A nurse is providing care for an elderly patient who is experiencing constipation.
What action should the nurse take?