The nurse identifies several nursing problems for a client with paraplegia who has been having fecal incontinence and diarrhea. The client's parent is the primary caregiver. In planning care, the nurse should determine which problem is the highest priority?

Fluid volume deficit.

Bowel incontinence.

Caregiver role strain.

Impaired bed mobility.

Answer and Explanation

The Correct Answer is A

Choice A Reason: This is correct because fluid volume deficit is a life-threatening condition that can result from diarrhea and fecal incontinence. The nurse should monitor the client's fluid intake and output, electrolytes, weight, urine specific gravity, and skin turgor.

Choice B Reason: This is incorrect because bowel incontinence is a significant problem that can affect the client's dignity, comfort, and skin integrity, but it is not as urgent as fluid volume deficit. The nurse should implement a bowel management program and provide appropriate hygiene and skin care.

Choice C Reason: This is incorrect because caregiver role strain is a potential problem that can affect the parent's well-being and ability to provide care, but it is not as critical as fluid volume deficit. The nurse should assess the parent's coping skills, support system, and respite needs.

Choice D Reason: This is incorrect because impaired bed mobility is a chronic problem that can affect the client's functional status and quality of life, but it is not as serious as fluid volume deficit. The nurse should assist the client with positioning, turning, transferring, and exercising.

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Correct Answer is A

Explanation

Choice A: Reassess the client and the level of pain is the correct intervention because it helps the nurse evaluate the effectiveness of the medication and plan further actions. The nurse should use a valid and reliable pain scale and check for any signs of adverse effects or complications.
Choice B: Tell the client the medication needs more time to work is not a correct intervention because it may dismiss the client’s pain and delay appropriate treatment. The nurse should acknowledge the client’s pain and explain the expected onset and duration of the medication.
Choice C: Ask the UAP to offer a backrub to the client is not a correct intervention because it may not be sufficient or appropriate for the client’s pain. The nurse should assess the client’s pain before delegating any nonpharmacological interventions to the UAP.
Choice D: Encourage the client to focus on taking deep breaths is not a correct intervention because it may not be effective or feasible for the client’s pain. The nurse should assess the client’s pain and offer other complementary therapies that are suitable and acceptable for the client.

A. Removes needle before discarding used syringes. B. Wears gloves to dispose of the needle and syringe. C. Washes hands before handling the needle and syringe. D. Dons a face mask before administering the medication.

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because removing needle before discarding used syringes may expose the client or others to accidental needlestick injuries. The needle and syringe should be disposed of as a single unit in a puncture-resistant container.

Choice B Reason: This is incorrect because wearing gloves to dispose of the needle and syringe is not necessary if the client does not have contact with blood or body fluids. Gloves are not a substitute for hand hygiene.

Choice C Reason: This is correct because washing hands before handling the needle and syringe reduces the risk of infection and contamination. Hand hygiene is the most important measure to prevent transmission of microorganisms.

Choice D Reason: This is incorrect because donning a face mask before administering the medication is not required unless the medication is aerosolized or nebulized. A face mask does not protect against needlestick injuries or bloodborne pathogens.

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The nurse identifies several nursing problems for a client with paraplegia who has been having fecal incontinence and diarrhea. The client's parent is the primary caregiver. In planning care, the nurse should determine which problem is the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After administering oxycodone to a client one hour ago, the client is reporting severe pain. Which intervention should the nurse implement next?

Correct Answer is A

Explanation

The nurse is teaching a client about use of the syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

Correct Answer is C

Explanation

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