Exhibits
A nurse is caring for a 44-year-old male client who had an anterior-posterior spinal fusion 3 days ago. The client is experiencing uncontrolled pain and has not had a bowel movement since the surgery. Which actions should the nurse take to assess the client's progress?
Select all that apply.
Administer a stool softener
Ask the client about their normal bowel routine
Hold the client's next meal
Perform a digital rectal exam
Discontinue morphine
Correct Answer : A,B,D
. Administer a stool softener: This could be a good option to consider, as the client has not had a bowel movement since the surgery. However, the nurse should first consult with the healthcare provider before administering any new medications.
B. Ask the client about their normal bowel routine: This is a good action to take. Understanding the client’s normal bowel routine can provide valuable context for the current situation.
C. Hold the client’s next meal: This may not be necessary at this point. The client’s regular diet has been ordered by the provider, and there’s no indication of nausea, vomiting, or other symptoms that would necessitate holding meals.
D. Perform a digital rectal exam: This could be considered if there’s a concern about impaction or other complications. However, this should only be done after consulting with the healthcare provider.
E. Discontinue morphine: This is not advisable based on the information provided. The client is reporting uncontrolled pain, and morphine has been ordered by the provider for pain management. Any changes to pain medication should be discussed with the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A thick, dry, and dark area on the heels could indicate a more advanced stage of a pressure injury, not the earliest indication.
Choice B rationale
Broken skin without evidence of undermining could also indicate a more advanced stage of a pressure injury.
Choice C rationale
A defined area of persistent redness over a bony prominence is often the earliest sign of a developing pressure injury. This is because these areas are more susceptible to pressure and have less padding to protect them.
Choice D rationale
A superficial sacral pressure injury with defined margins is a more advanced stage of a pressure injury.
Correct Answer is D
Explanation
Choice A rationale
Replacing paper trash bags with plastic biohazard bags is not typically necessary in a mental health unit unless there is a risk of exposure to blood or other potentially infectious materials. This action would not specifically address the safety needs of a patient with depression following a positive HIV diagnosis16.
Choice B rationale
Removing soft drink cans from the nurse’s desk and patient lounge is not typically necessary for ensuring a safe environment for a patient with depression following a positive HIV diagnosis. This action does not directly address the patient’s mental health needs16.
Choice C rationale
Confiscating the patient’s cellular phone and providing a room telephone is not typically necessary for ensuring a safe environment for a patient with depression following a positive HIV diagnosis. While some facilities may have policies regarding the use of personal electronic devices, this action does not directly address the patient’s mental health needs16.
Choice D rationale
Ensuring that prescribed medications are securely stored in the room is the correct action. This is a standard safety measure in healthcare settings to prevent medication errors and misuse. It is particularly important for patients with depression who may be at risk for self-harm16.
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