The nurse anticipates the need for a(n)
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C","dropdown-group-3":"B"}
Rationale for correct choices
• Laxative: The client is postoperative day 3 and reports not having had a bowel movement, which is common after abdominal surgery due to anesthesia, opioid use, and decreased mobility. The return of flatus indicates partial return of bowel function, making a laxative appropriate to stimulate bowel evacuation. Early management helps prevent postoperative ileus and discomfort.
• Bowel movements: Absence of bowel movements by postoperative day 3 signals delayed gastrointestinal motility. This finding indicates the need for intervention to promote normal elimination. Monitoring bowel movement patterns helps guide appropriate pharmacologic and nonpharmacologic interventions.
• Bowel sounds: The client has hypoactive bowel sounds, suggesting slowed intestinal activity following surgery. Hypoactive sounds combined with lack of bowel movement indicate decreased peristalsis rather than obstruction. This assessment finding supports the use of a laxative once flatus is present.
Rationale for incorrect choices
• Antiemetic: The client is not currently reporting nausea or vomiting. Gastrointestinal symptoms are related to decreased motility rather than upper GI upset. An antiemetic would not address constipation or delayed bowel function.
• Antidiarrheal: The client does not have diarrhea and has not had any bowel movements. Using an antidiarrheal would further slow intestinal motility and worsen constipation. This intervention would be inappropriate in the current postoperative context.
• Findings at incision site: Although purulent drainage and swelling suggest possible infection, these findings do not indicate the need for a laxative. Incisional findings are more relevant to antibiotic therapy or wound management. They do not explain delayed bowel elimination.
• Abdominal distention: The abdomen is soft and nondistended on assessment. Distention would suggest gas or obstruction, which is not present. The primary indicators remain bowel sounds and bowel movement status.
• Incisional tenderness: Incisional tenderness is expected after abdominal surgery and reflects tissue healing or inflammation. It does not directly influence bowel motility or elimination. Pain alone does not justify laxative use. This finding is unrelated to gastrointestinal function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "We should establish our roles in the initial session.": During the orientation phase of the therapeutic relationship, the nurse and client define the purpose of the relationship, clarify roles, and establish trust. Setting clear expectations helps the client feel safe and provides a framework for subsequent therapeutic work.
B. "Let me show you simple relaxation exercises to manage stress.": Teaching relaxation techniques occurs in the working phase of the therapeutic relationship, when the client is actively addressing anxiety symptoms and developing coping strategies. It is not the focus during orientation.
C. "We should discuss resources to implement in your daily life.": Discussing resources and practical interventions is part of the working or termination phase, after rapport has been established and the client is ready to apply strategies outside the therapeutic setting.
D. "Let's talk about how you can change your response to stress.": Exploring behavioral change and coping strategies is a component of the working phase. The orientation phase is intended for establishing trust, setting goals, and defining roles rather than implementing interventions.
Correct Answer is D
Explanation
A. Irrigate the wound with sterile water: Irrigation may be appropriate after bleeding is controlled, but during active hemorrhage, immediate pressure to control blood loss takes priority over wound cleansing. Delaying hemostasis can lead to hypovolemic shock.
B. Tie a tourniquet around the leg distal to the wound: Tourniquets are reserved for life-threatening hemorrhage when direct pressure fails. Improper placement distal to the wound may be ineffective; tourniquet application should be proximal to the injury if used.
C. Apply a transparent dressing to the wound: Transparent dressings are not suitable for active, profuse bleeding because they do not provide adequate pressure to control hemorrhage. They are more appropriate for observation of healing wounds.
D. Apply direct pressure to the wound with thick dressing material: Direct pressure with sterile or thick dressings is the first-line intervention for controlling active external bleeding. It compresses blood vessels, promotes clot formation, and stabilizes the client until further medical intervention.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.