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.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is ["C","D","E","F","G","H","J"]

Explanation

Based on the provided information, the following assessment findings require immediate follow-up by the nurse:

Difficulty breathing on a hike: This is a significant symptom of asthma exacerbation and needs immediate attention.
Symptoms did not resolve after taking albuterol: Albuterol is a quick-relief medication for asthma symptoms. If symptoms do not improve after its use, it indicates that the asthma exacerbation is severe.
Mild subcostal retractions: This is a sign of respiratory distress and indicates that the client is using accessory muscles to breathe.
Wheezes noted throughout the lung fields: Wheezing is a common sign of asthma and indicates airway obstruction.
The client is pale: Paleness can be a sign of decreased oxygenation.
Heart rate of 122 beats/minute: A high heart rate can be a sign of distress or could be due to the body’s attempt to compensate for decreased oxygenation.
Oxygen saturation of 91% on room air: Normal oxygen saturation is typically 95% or higher. A saturation of 91% indicates that the client is not getting enough oxygen.

A. Reassure the client that the nurse will return after all vital signs are taken. B. Pull up a chair and sit beside the client’s bed. C. Allow the client to hold the nurse’s hand until the vital signs can be completed. D. Tell the client that he must release the nurse’s hand.

Correct Answer is B

Explanation

Choice A rationale

Reassuring the client that the nurse will return after all vital signs are taken might not be the most appropriate action in this situation. The client is critically ill and might need immediate emotional support.

Choice B rationale

Pulling up a chair and sitting beside the client’s bed is the most appropriate action. This action shows empathy and provides emotional support, which is crucial in the care of critically ill patients.

Choice C rationale

Allowing the client to hold the nurse’s hand until the vital signs can be completed might provide some comfort to the client. However, it might not be feasible if the nurse needs to use both hands to complete the vital signs.

Choice D rationale

Telling the client that he must release the nurse’s hand might not be the most appropriate action. It might come across as dismissive and could potentially upset the client.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["C","D","E","F","G","H","J"]

Explanation

While taking vital signs, a critically ill male client grabs the nurse’s hand and asks the nurse not to leave.What is the most appropriate action for the nurse to take?

Correct Answer is B

Explanation

When developing an educational program for older adult clients who are being discharged with new antihypertensive medications, which characteristics should the nurse ensure that the educational materials include? Select all that apply.

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