Try Naxlex NCLEX-RN (Free-Trial)

The nurse has assessed the client, analyzed the data, and identified constipation as a patient health problem.
Which assessment cues would support constipation? Select all that apply.

Stool is hard and has a consistency of small marbles.

Bowel sounds are hyperactive in all four quadrants.

Client reports they have not had a bowel movement for the past 4 days.

Client reports urgency when needing to have a bowel movement.

Client states they have to strain hard when having a bowel movement.

Answer and Explanation

Correct Answer : A,C,E

The correct answer is choices A, C, and E.

Stool is hard and has a consistency of small marbles is a sign of constipation.
Bowel sounds that are hyperactive in all four quadrants are an indication of diarrhea rather than constipation.
Client reports they have not had a bowel movement for the past 4 days supports the diagnosis of constipation.
Client reports urgency when needing to have a bowel movement is more indicative of diarrhea than constipation.
Client states they have to strain hard when having a bowel movement is a sign of constipation.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

The correct answer is choice C: Listen with the stethoscope at the fifth intercostal space left mid clavicular line. This is the correct location to auscultate the apical pulse or apical heart rate. The apical pulse is the sound of the heart beating heard through a stethoscope placed over the apex of the heart, which is located at the fifth intercostal space at the left mid-clavicular line. The second intercostal space at the left sternum is the location to auscultate the aortic valve, while the fifth intercostal space at the sternum is the location to auscultate the tricuspid valve. The neck to the right of the coracoid process is not a location to auscultate the apical pulse.

A. The nurse applies sterile gloves and touches a sterile object in the sterile field. B. The nurse disposes of an opened container of sterile saline after 24 hours. C. The nurse turns and their back is facing the sterile field. D. The nurse keeps hands above waist level while donning sterile gloves.

Correct Answer is C

Explanation

Correct answer: C

C. The nurse turns and their back is facing the sterile field.Turning one’s back to the sterile field is a breach of sterile technique because it increases the risk of contamination. The sterile field must always be in the nurse’s line of sight to ensure it remains uncontaminated.

Incorrect Options:

A. The nurse applies sterile gloves and touches a sterile object in the sterile field.This is correct practice. Sterile gloves are used to handle sterile objects within the sterile field to maintain sterility.

B. The nurse disposes of an opened container of sterile saline after 24 hours.This is correct practice. Sterile saline should be discarded after 24 hours to prevent contamination.

D. The nurse keeps hands above waist level while donning sterile gloves.This is correct practice. Keeping hands above waist level helps maintain sterility by preventing contact with non-sterile surfaces.

View Question and Answer

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

The nurse has assessed the client, analyzed the data, and identified constipation as a patient health problem. Which assessment cues would support constipation? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse can most accurately assess a client's apical heart rate by which of the following methods?

Correct Answer is C

Explanation

A new perioperative nurse is being educated regarding surgical asepsis. What observations by the preceptor would indicate that there is a need for further education and reinforcement of the principles of asepsis?

Correct Answer is C

Explanation

The nurse is teaching a patient with a new ostomy about skin care to preserve tissue integrity. What teaching will the nurse provide about cleansing the ostomy area?

The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse should place the client in which position for insertion?

A new nurse understands that documentation guidelines are important to ensure accuracy. The nurse would perform which of the following documentation guidelines? Select all that apply.

A nurse is caring for a client who is being treated for bladder infection. The client reports to the nurse that he has been having painful burning with urination. How should the nurse document the client's condition?

A nurse is caring for a client with a wound on the lower extremity. What findings would the nurse observe that would indicate a wound infection?

A nurse is assessing a patient and notes that the patient is experiencing hypoxia. Which of the following patient signs would indicate that the patient has hypoxia? Select all that apply.

A nurse is implementing interventions to prevent a patient from developing Deep Vein Thrombosis (DVT) in the legs by applying a pneumatic or sequential compression device (SCD's). Which explanation would the nurse give the patient in regards to how this device works?

The nurse has assessed the client, analyzed the data, and identified constipation as a patient health problem.
Which assessment cues would support constipation? Select all that apply.