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 C
Explanation
A. This statement is incorrect; exercise can significantly affect blood glucose levels by improving insulin sensitivity and helping with glycemic control.
B. Soaking feet in hot water is not recommended as it can lead to burns or injuries, especially in individuals with reduced sensation.
C. Limiting alcoholic beverages to 1-2 per day is generally acceptable for most individuals with diabetes, as long as it is done cautiously and with food to prevent hypoglycemia.
D. While keeping wounds covered is important, simply using antibiotic ointment may not be sufficient, and proper wound care should be emphasized.
Correct Answer is ["A","F"]
Explanation
A. After successful weaning, the client will need supplemental oxygen via nasal cannula or face mask to ensure continued oxygenation post-extubation.
B. The current weaning process is progressing as expected with pressure support decreasing steadily. There is no indication that a different ventilator mode is necessary at this time.
C. There is no indication in the scenario that the client requires a nasogastric tube for ventilation weaning or extubation.
D. The fraction of inspired oxygen (FiO₂) is currently at 35%, which is appropriate during the weaning process. Increasing FiO₂ without indication could disrupt the weaning progression.
E. The weaning process is designed to gradually reduce support. Adding mandatory breaths would counteract the progress made in reducing ventilatory support.
F. The client has been weaned to minimal ventilatory support, which suggests the healthcare provider may plan for extubation. Having supplies ready will facilitate a smooth extubation process.
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