The nurse is completing an assessment of an older adult client recovering from a total hip replacement. The client reports a decreased appetite and is concerned about having not had a bowel movement for several days. Which intervention should the nurse implement first?

Increase fiber in diet and add daily prune juice.

Assess type and frequency of physical activities.

Perform a digital examination for fecal impaction.

Check bowel sounds and abdominal tenderness.

Answer and Explanation

The Correct Answer is D

A.   Increasing dietary fiber and adding prune juice can help relieve constipation by improving bowel regularity. While this is an important step in managing constipation, it is not the first action to take without understanding the underlying cause or current status of bowel function.
B.   Physical activity is important for bowel regularity, especially post-surgery. However, assessing physical activity should come after a more immediate evaluation of the client's bowel status. It is crucial to first determine if there are other underlying issues that need addressing before implementing dietary changes or increasing activity.
C.   A digital examination can be necessary to identify fecal impaction, especially if other assessments suggest severe constipation or if the client has not had a bowel movement for several days. However, this is an invasive procedure and should be performed based on preliminary findings from non-invasive assessments.
D.   Checking bowel sounds and abdominal tenderness is an essential first step in assessing the client's gastrointestinal status. It helps identify whether there is a lack of bowel movement due to a more severe issue such as bowel obstruction or if it is simply a case of constipation.

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Correct Answer is C

Explanation

A. Debriding agents are used to remove necrotic or non-viable tissue from a wound. While debridement can be necessary if there is evidence of necrotic tissue or eschar, the presence of thick tan exudate alone does not necessarily indicate that debridement is needed.
B. Steri-strips are used to support wound closure and can be applied to wounds with approximated edges. However, in the case of a wound healing by secondary intention (where the edges are not brought together but heal from the inside out), steri-strips are not typically used. This action is not relevant if the wound is healing by secondary intention and if there is a thick exudate present.
C. Obtaining a wound culture is important if there is a suspicion of infection, especially if there is a change in the character of the exudate, increased redness, swelling, or other signs of infection. A thick tan exudate might be indicative of an infection or could be a normal part of the healing process
D. Removing sutures in a wound that is healing by secondary intention is not appropriate as it could disrupt the healing process and potentially lead to complications. Sutures are typically removed when the wound is healing by primary intention and the edges are approximated.

A. Absorbent undergarments dry for 6 hours. B. Heel dressing saturated with serous drainage. C. Frequent request for medication to sleep. D. Confusion to time, place, and environment.

Correct Answer is D

Explanation

A. While the use of absorbent undergarments is relevant to managing urinary incontinence, having them dry for 6 hours indicates that they are performing their function well in terms of absorbing urine. This finding does not immediately suggest a new issue that needs urgent further assessment.
B. A heel dressing saturated with serous drainage suggests that the stage II pressure ulcer on the left heel is producing a significant amount of fluid. Serous drainage is typically clear or light yellow and can indicate a wound that is still in the inflammatory phase of healing
C. Frequent requests for sleep medication can indicate issues with sleep patterns or underlying psychological stress. While it’s important to address sleep difficulties, this finding might not be as immediately critical as other concerns but warrants further assessment to address possible underlying causes and manage sleep issues appropriately.
D. Confusion about time, place, and environment in a newly admitted client is a significant finding and requires urgent further assessment. This level of confusion could be indicative of a serious issue such as delirium, which can be caused by various factors including infection, dehydration, metabolic imbalances, or a sudden change in environment.

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The nurse is completing an assessment of an older adult client recovering from a total hip replacement. The client reports a decreased appetite and is concerned about having not had a bowel movement for several days. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A surgical incision that is healing by secondary intention develops a thick tan exudate. Which action should the nurse take first?

Correct Answer is C

Explanation

An older adult client is admitted to a long term care facility. Upon admission, the client is oriented but fatigued, is incontinent of urine, and has a stage II pressure ulcer on the left heel. Which additional finding requires further assessment?

Correct Answer is D

Explanation

A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

The nurse finds a confused client wandering in the hallway during the night. Which actions should the nurse implement? Select all that apply.

An older adult client residing in a long-term care facility has become disoriented and suddenly develops urinary incontinence. Which intervention should the nurse implement?

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While inserting an indwelling urinary catheter into a female client, the nurse observes urine flow in the tubing. Which action should be taken next?

When identifying the goals to be included in a client's plan of care, the nurse should take which action?