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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale

Production of extra platelets is not the primary pathophysiological process in Disseminated Intravascular Coagulation (DIC). While the body may try to produce more platelets in response to the widespread clotting, this is not the cause of the coagulation problem.

Choice B rationale

Depletion of clotting factors is a key feature of DIC. In the initial phase of DIC, there is an overactive clotting process leading to the formation of small blood clots throughout the body’s blood vessels. This overactive clotting uses up platelets and clotting factors, leading to a state where the body is unable to control bleeding, which is the second phase of DIC34.

Choice C rationale

Inhibition of red blood cell production is not a primary feature of DIC. While DIC can lead to anemia due to blood loss from excessive bleeding, it does not directly inhibit the production of red blood cells.

Choice D rationale

Activation of complement pathways is part of the body’s immune response and is not the primary cause of the coagulation problem in DIC34.

A. Client’s healthcare power of attorney. B. Currently prescribed medications. C. Fall at home as reason for admission. D. Increasing confusion of the patient.

Correct Answer is D

Explanation

Choice A rationale

While the client’s healthcare power of attorney is important information, it is not the most critical piece of information to report in this situation. The immediate concern is the client’s change in mental status and potential medical emergency.

Choice B rationale

The nurse should be aware of the client’s currently prescribed medications, but this information does not take precedence over the client’s sudden onset of confusion and agitation. Immediate action is needed to address the client’s altered mental status.

Choice C rationale

While the reason for the client’s admission is important background information, it is not the most urgent information to report in this situation. The priority is addressing the client’s acute change in mental status.

Choice D rationale

Increasing confusion and agitation in a client who recently underwent ORIF of the right femur is a significant change in condition and may indicate a medical emergency such as infection, delirium, or other complications. This information should be provided first to alert the healthcare provider to the client’s immediate needs.

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Naxlex Comprehensive Predictor Exams

A patient with septic shock develops Disseminated Intravascular Coagulation (DIC). Which pathophysiological process should the nurse identify as the cause of the coagulation problem?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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