On the first postoperative day, the nurse finds an older adult client disoriented and trying to climb over the bed railing. The client was oriented to person, place, and time on admission. Which intervention should the nurse implement first?

Assess the client for pain.

Apply wrist restraints.

Determine the client's blood pressure.

Administer a mild sedative.

Answer and Explanation

The Correct Answer is A

A.   Assessing the client for pain is a crucial step because pain can cause disorientation and agitation, especially after surgery. Pain might be a reason for the client's behavior. Addressing pain effectively can help improve the client’s comfort and potentially reduce disorientation and risky behavior.
B.   Applying wrist restraints should be considered a last resort and only when other interventions are not effective or if there is an immediate danger to the client. Restraints can increase agitation and potentially lead to other complications.
C.   Determining the client's blood pressure can be important, especially if there are concerns about hypotension or other cardiovascular issues that might contribute to disorientation. However, it is usually more effective to first address potential pain or discomfort.
D.   Administering a sedative may be appropriate in cases of severe agitation or disorientation, but it should not be the first action. It is essential to first identify and address any underlying causes of the client’s behavior, such as pain, before resorting to pharmacological interventions.

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Correct Answer is C

Explanation

A. While notifying the healthcare provider may be necessary in some cases, it's not the most immediate or appropriate action in this situation. The nurse can address the client's concerns directly by providing a bedside commode.
B. While having a UAP available for assistance can be helpful, providing a bedside commode is a more practical and efficient solution.
C. A bedside commode can help prevent accidents and spills, which can be embarrassing and contribute to a negative experience. Offering a bedside commode demonstrates respect for the client's concerns and preferences, which can help to build trust and improve the overall care experience.
D. A bedpan may not be as comfortable or convenient for the client as a bedside commode, especially if they have mobility limitations.

A. Take an over-the-counter laxative every morning. B. Drink six to eight large glasses of water daily. C. Try using over-the-counter enemas when needed. D. Walk around the block or further every day.

Correct Answer is B

Explanation

A. While over-the-counter laxatives can be effective for relieving constipation, they are typically recommended for short-term use or when dietary and lifestyle changes have not resolved the issue. Regular or frequent use of laxatives can lead to dependence and potentially worsen constipation over time.
B. Increasing water intake is a highly effective way to address constipation. Adequate hydration helps soften the stool, making it easier to pass. Drinking six to eight large glasses of water daily is a good strategy to promote regular bowel movements and prevent constipation.
C. Over-the-counter enemas can provide immediate relief from constipation but should not be used frequently. Enemas are more invasive and can cause discomfort or lead to dependency if used too often. They are typically recommended for occasional use rather than as a first-line solution for chronic constipation.
D. Regular physical activity, such as walking, can help stimulate bowel movements and alleviate constipation. Exercise promotes gut motility and can be an effective part of a comprehensive approach to managing constipation.

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On the first postoperative day, the nurse finds an older adult client disoriented and trying to climb over the bed railing. The client was oriented to person, place, and time on admission. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Prior to receiving a 120 mL hypertonic enema, an ambulatory female client tells the nurse that she does not believe that she can walk all the way to the bathroom without expelling the enema. Which intervention is best for the nurse to implement?

Correct Answer is C

Explanation

A client in the outpatient clinic reports experiencing hard, infrequent stools. Which instruction should the nurse provide this client?

Correct Answer is B

Explanation

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