A patient with a hip fracture is having difficulty defecating into a bedpan while lying in bed. Which action by the nurse will assist the patient in having a successful bowel movement?

Withholding narcotic pain medication

Raising the head of the bed

Administering laxatives to the patient

Preparing to administer a barium enema

Answer and Explanation

The Correct Answer is B

A. Withholding pain medication could result in increased discomfort, which may further hinder the patient’s ability to defecate.

B. Raising the head of the bed promotes a more natural position for defecation, making it easier for the patient to use the bedpan.

C. Administering laxatives may be necessary in some cases but is not the first intervention to assist with positioning and comfort during defecation.

D. A barium enema is a diagnostic tool, not an appropriate intervention for immediate defecation assistance.

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Correct Answer is C

Explanation

A. Sanguineous drainage consists mostly of blood and is bright red, indicating active bleeding.

B. Serous drainage is clear or slightly yellowish and watery, often seen in healing wounds.

C. Serosanguineous drainage is a mixture of blood and serous fluid, which is watery with a pink or reddish tinge, common in early wound healing.

D. Purulent drainage is thick and cloudy, indicating infection, usually accompanied by an unpleasant odor.

A. Elevate the head of the bed no more than 45°. B. Apply baby powder to keep sensitive skin areas dry. C. Lift, rather than pull, to lift the client up in bed. D. Massage the reddened skin over the client's bony prominences.

Correct Answer is C

Explanation

A. The head of the bed should be elevated no more than 30° to prevent shearing forces on the skin.

B. Baby powder can cause dryness and irritation rather than protecting the skin.

C. Lifting rather than pulling reduces the risk of friction and shearing forces, which can lead to skin breakdown and pressure ulcers.

D. Massaging reddened skin over bony prominences can damage already compromised tissue and increase the risk of pressure ulcers.

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A patient with a hip fracture is having difficulty defecating into a bedpan while lying in bed. Which action by the nurse will assist the patient in having a successful bowel movement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following?

Correct Answer is C

Explanation

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Correct Answer is C

Explanation

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