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 []
Explanation
Potential Condition
Polycythemia
Tetralogy of Fallot, a congenital heart condition, often leads to decreased oxygenation, which triggers the body to produce more red blood cells to compensate, resulting in polycythemia.
Actions the nurse should take:
Take the child’s vital signs: Monitoring vital signs is essential to assess the child's overall stability and detect any signs of distress or hypoxia.
Ask the child’s parents about the frequency of tet spells: Tet spells (hypercyanotic episodes) are common in children with Tetralogy of Fallot, and understanding their frequency helps assess the child's current condition and plan interventions.
Parameters to monitor:
Oxygen saturation: Monitoring oxygen levels is crucial to determine how well the child is oxygenating and to detect any hypoxia or cyanosis.
Weight: Monitoring weight is important in this child, who is in the lower percentiles for growth, as poor weight gain may indicate the need for nutritional or medical intervention.
Correct Answer is D
Explanation
A. Assessing the level of consciousness is important for monitoring sedation but does not directly measure pain control.
B. Monitoring respiratory rate is crucial for safety with opioid use, but it does not assess the effectiveness of pain relief.
C. Blood pressure may vary with pain levels but is not a direct measure of the effectiveness of analgesia.
D. Assessing the pain scale is essential to determine if the client is experiencing adequate pain relief with the current dose of hydromorphone, ensuring that the equianalgesic dosing is effective.
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