The nurse is assessing the patient's output for the shift. What finding is most concerning?

Green, soft stool after the patient received antibiotics

Large, loose stool after the patient received a laxative

Dry, hard stool from a patient receiving opiates.

Black tarry stool from a patient receiving an anticoagulant

Answer and Explanation

The Correct Answer is D

A. Green, soft stool after the patient received antibiotics: Green stool can be a side effect of antibiotics due to changes in gut flora but is not typically concerning.

B. Large, loose stool after the patient received a laxative: This is an expected outcome of laxative use and is not cause for concern.

C. Dry, hard stool from a patient receiving opiates: Opiates commonly cause constipation. While this requires management, it is not the most concerning finding.

D. Black tarry stool from a patient receiving an anticoagulant: Black tarry stool (melena) indicates gastrointestinal bleeding, which can be life-threatening, especially in a patient on anticoagulants. Immediate assessment is required.

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Correct Answer is C

Explanation

A. It is painful to sit on a bedpan. Discomfort may be a factor, but pain alone does not explain the difficulty in having a bowel movement.
B. The position encourages the Valsalva maneuver. The Valsalva maneuver (straining against a closed airway) can occur in any position, but posture is the primary problem here.
C. The position does not facilitate downward pressure. The seated position allows for gravity and proper abdominal muscle engagement, making defecation easier. Lying down does not facilitate intra-abdominal pressure.
D. The cause is unknown and requires further study. The relationship between position and defecation is well understood in physiology.

A. Avoid using your fingers to open the mouth. B. Apply moisturizer to the oral mucosa and lips. C. Brush the teeth with a soft bristled toothbrush D. Use a toothbrush with a suction attachment

Correct Answer is D

Explanation

A. Avoid using your fingers to open the mouth: While this is a safety measure to prevent injury, it is not the most important intervention.

B. Apply moisturizer to the oral mucosa and lips: While this is beneficial for comfort, preventing aspiration and maintaining airway patency are higher priorities.

C. Brush the teeth with a soft-bristled toothbrush: Oral hygiene is important, but the highest priority is preventing aspiration.

D. Use a toothbrush with a suction attachment: Suction prevents the accumulation of oral secretions, reducing the risk of aspiration pneumonia in a sedated patient.

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The nurse is assessing the patient's output for the shift. What finding is most concerning?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is having difficulty having a bowel movement laying on the bedpan. What is the physiologic reason for this problem?

Correct Answer is C

Explanation

The nurse is providing oral care to a sedated patient. What intervention is most important to implement with this patient?

Correct Answer is D

Explanation

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