Exhibits
Review H and P, nurse's note, flow sheet, and orders.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Potential condition
Opioid-induced constipation
The client’s report of no bowel movement since surgery, along with the use of morphine for pain management, suggests opioid-induced constipation. Opioids are known to slow down gastrointestinal motility.
Actions to Take:
Administer a stool softener
Stool softeners can help ease bowel movements by softening the stool, which is a common intervention for constipation, particularly opioid-induced.
Ask the client about ambulation
Encouraging ambulation is an effective way to stimulate gastrointestinal motility and reduce the risk of constipation.
Parameters to Monitor:
Fluid intake
Adequate hydration is crucial for maintaining proper bowel function, especially when using stool softeners or other constipation treatments.
Intraabdominal pressure
Monitoring intraabdominal pressure can help assess for severe constipation or potential complications, such as bowel obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
Respirations: Morphine is an opioid analgesic that can cause respiratory depression, so monitoring the client's respiratory status is crucial after administration.
Ice application to the shoulder: Applying ice can help reduce swelling and inflammation in the injured area. This is important for managing pain and preventing further complications, such as excessive swelling or damage to surrounding tissues.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
Explanation
This client is at risk for VTE due to several factors, including being postpartum, prolonged labor (25 hours), and potential immobility after delivery. Additionally, the presence of a 4th-degree laceration may lead to decreased mobility, increasing the risk of blood clots.
Wound Dehiscence:
The client has a 4th-degree laceration, which involves a significant degree of tissue damage and may require careful monitoring for proper healing. Factors such as infection (noted by slight fever), tension on the wound, or inadequate healing can contribute to the risk of dehiscence.-
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