Before administering a laxative to a bedfast client, it is most important for the nurse to perform which assessment?

Evaluate the client's ability to recognize the urge to defecate.

Determine the frequency and consistency of bowel movements.

Observe the skin integrity of the client's rectal and sacral areas.

Assess the client's strength in moving and turning in the bed.

Answer and Explanation

The Correct Answer is B

A) Evaluate the client's ability to recognize the urge to defecate: Assessing the client's ability to recognize the urge to defecate is important for promoting independence in toileting. However, this assessment may not directly indicate the need for administering a laxative. It is more relevant for clients who are able to ambulate or have control over their bowel movements.

B) Determine the frequency and consistency of bowel movements: Assessing the frequency and consistency of bowel movements provides valuable information about the client's bowel function and helps determine the need for a laxative. It allows the nurse to establish a baseline and evaluate the effectiveness of interventions. Understanding the client's typical bowel pattern is crucial before administering a laxative to avoid overmedication or potential complications such as diarrhea or fecal impaction.

C) Observe the skin integrity of the client's rectal and sacral areas: Assessing skin integrity in the rectal and sacral areas is crucial for preventing pressure ulcers, especially in bedfast clients. However, it is not directly related to the need for administering a laxative.

D) Assess the client's strength in moving and turning in the bed: While assessing the client's strength and mobility is important for overall care and prevention of complications related to immobility, it may not be directly related to the need for administering a laxative. This assessment is more relevant for preventing complications such as pressure ulcers and maintaining musculoskeletal function.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A) Hold the dose and notify the pharmacy to stop dispensing the next premixed doses: This action may prevent further administration of fluconazole, but it does not address the underlying concern of rising liver enzyme levels. Holding the dose and notifying the healthcare provider directly would be more appropriate.

B) Hold the dose and notify the healthcare provider of the changes in the laboratory studies: This is the correct response. RisIng liver enzyme levels, indIcated by an increasing trend in aspartate aminotransferase (AST), suggest potential liver dysfunction or damage, which can be a serious adverse effect of fluconazole. The nurse should hold the dose and promptly inform the healthcare provider for further evaluation and management.

C) Begin the infusion and monitor the client's bl’od urea nitrogen (BUN), serum creatinine, and liver function tests: Initiating the infusion without addressing the rising liver enzyme levels could potentially worsen liver function. It is essential to hold the dose and inform the healthcare provider before proceeding with further administration.

D) Begin the infusion and submit a drug reaction report to the nursing supervisor: While it's im’ortant to document adverse reactions and submit reports as appropriate, the priority in this situation is to hold the dose and notify the healthcare provider to address the rising liver enzyme levels.

A. Cheese, milk, and yogurt. B. Bananas, oranges, and peaches. C. Pasta, cereal, and bread. D. Liver, beef, and chicken.

Correct Answer is B

Explanation

A) Cheese, milk, and yogurt: These foods are high in calcium and may not be the best choice for a client taking furosemide, as they can contribute to calcium levels and potentially exacerbate hypercalcemia, which is a risk with loop diuretic use.

B) Bananas, oranges, and peaches: This is the correct response. These fruits are rich in potassium, which is often depleted in clients taking loop diuretics like furosemide. Encouraging foods high in potassium can help replenish electrolytes and prevent hypokalemia.

C) Pasta, cereal, and bread: While these foods are generally well-tolerated and can provide carbohydrates for energy, they do not specifically address the electrolyte imbalances associated with loop diuretic use.

D) Liver, beef, and chicken: These foods are good sources of protein but do not directly address the electrolyte imbalances associated with loop diuretic use.

Therefore, encouraging the client to consume foods rich in potassium, such as bananas, oranges, and peaches, can help offset the potassium loss caused by furosemide and mitigate the risk of hypokalemia.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Before administering a laxative to a bedfast client, it is most important for the nurse to perform which assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is administering IV fluconazole to a client who has systemic candidiasis. After reviewing the client's di’gnostic studies, the nurse identifies a rising trend in the liver enzyme levels for aspartate aminotransferase (AST). Which action should the nurse implement?

Correct Answer is B

Explanation

The loop diuretic furosemide is prescribed for a client with a history of heart failure (HF). Which foods should the nurse encourage this client to eat?

Correct Answer is B

Explanation

Before administering the initial dose of sumatriptan succinate to a client with a migraine headache, it is most important to determine if the client's hi’tory includes which problem?

A client is scheduled for a spiral computed tomography (CT) scan with contrast to evaluate for pulmonary embolism. Which information in the client’s history requires follow up by the nurse?

A peak and trough level was obtained from a client receiving an aminoglycoside IV every 8 hours. Which finding presents the highest risk for the client and should be reported immediately to the healthcare provider?

A young adult female client who is planning to become pregnant asks the nurse if she can continue taking isotretinoin for cystic acne. Which information is most important for the nurse to provide this client?

A male client has been receiving the antibiotic gentamicin sulfate, IV piggyback every 12 hours for several days. Which observation by the nurse indicates that the client may be experiencing an adverse effect of gentamicin? Reference Range: White Blood Cell [5000 to 10,000/mm3 (5 to 10 x 10%)]

A client with myasthenia gravis receives a now prescription for pyridostigmine. Which information should the nurse obtain to prior to administering the medication?

The nurse is reviewing the client’s laboratory results. Based on a client’s serum digoxin level, the client is diagnosed with digoxin toxicity. Which action should the nurse expect to implement?