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.

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Correct Answer is B

Explanation

Recommend use of an over-the-counter antipyretic: While treating fever with an antipyretic like acetaminophen or ibuprofen may provide symptomatic relief, the priority in this scenario is to assess for other adverse effects of the medication. Fever can be a sign of an allergic reaction or other adverse effects to the antibiotic. Therefore, it is important to first assess for other symptoms before recommending symptomatic treatment.

B) Determine if other adverse effects have developed: This is the correct answer. The onset of a low-grade fever after starting a new medication, such as amoxicillin, warrants further assessment for other adverse effects. The nurse should inquire about other symptoms the client may be experiencing, such as rash, itching, swelling, difficulty breathing, or gastrointestinal disturbances, which could indicate an allergic reaction or other adverse effects.

C) Ask if the medication has been kept refrigerated: While it is important to ensure proper storage of medications, such as amoxicillin, which may require refrigeration, the onset of a low-grade fever is not typically related to medication storage. Therefore, this action would not address the client’s current symptoms and concerns.

D) Instruct the client to increase oral fluid intake: While maintaining adequate hydration is important for overall health and may help manage symptoms of illness, such as fever, the priority in this scenario is to assess for other adverse effects of the medication. Therefore, increasing oral fluid intake alone would not address the potential adverse effects of amoxicillin.

A. CT scan that was performed six months earlier. B. Takes metformin hydrochloride for type 2 diabetes mellitus. C. Report of client’s sobriety for the last five years. D. Metal hip prosthesis was placed twenty years ago.

Correct Answer is B

Explanation

A) CT scan that was performed six months earlier: A previous CT scan performed six months earlier does not necessarily require follow-up by the nurse. However, it would be important to review the results of the previous CT scan to compare findings and assess for any changes over time.

B) Takes metformin hydrochloride for type 2 diabetes mellitus: This is the correct answer. Metformin is excreted by the kidneys, and contrast media used in CT scans can potentially cause kidney damage, particularly in clients with pre-existing renal impairment. Therefore, clients taking metformin may be at increased risk of developing lactic acidosis if renal function is compromised. It is essential for the nurse to follow up on this information and coordinate with the healthcare provider to determine whether metformin should be temporarily discontinued before the CT scan and when it can be safely resumed.

C) Report of client’s sobriety for the last five years: The client’s sobriety status for the last five years is not directly relevant to the CT scan with contrast for evaluating pulmonary embolism. While substance use history is important for overall health assessment, it does not specifically require follow-up related to the CT scan.

D) Metal hip prosthesis was placed twenty years ago: The presence of a metal hip prosthesis placed twenty years ago may be relevant for certain imaging studies, such as magnetic resonance imaging (MRI) or metal artifact reduction sequence (MARS) MRI, but it is not directly related to the CT scan with contrast for pulmonary embolism evaluation. Therefore, it does not require immediate follow-up by the nurse in this context.

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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

Six days after starting a prescription of an oral amoxicillin solution, a client calls the clinic to report the onset of a low grade fever. Which action should the nurse Implement?

Correct Answer is B

Explanation

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?

Correct Answer is B

Explanation

A client reports confusion and blurred vision after receiving a dose of glipizide. Which action should the nurse implement?

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When administering zolpidem to an older client, which computer documentation indicates that the desired outcome has been achieved?

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