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 B

Explanation

A. The dropper should already be positioned correctly, with the tip pointing toward the ear canal.
B. For adolescents and adults, the auricle (outer ear) should be pulled up and out to straighten the ear canal. This allows the ear drops to flow directly into the ear canal, avoiding the tympanic membrane (eardrum). Correctly positioning the auricle helps to prevent irritation and discomfort during ear drop administration.
C. While visualizing the eardrum is important for certain procedures, it's not necessary when administering ear drops.
D. The ear drops should be administered after the auricle is pulled up and out to ensure proper placement in the ear canal.

A. Establish mental status baseline. B. Insert an indwelling urinary catheter. C. Check the accuracy of medication list. D. Obtain a capillary blood glucose level.

Correct Answer is D

Explanation

A. While establishing a mental status baseline is important for assessing the client's overall neurological condition and any potential changes in consciousness or cognition, it is not the immediate priority in this case.
B. Inserting a urinary catheter might be necessary for monitoring urine output, especially if there are concerns about fluid balance or kidney function. However, it is not the immediate priority in this scenario unless there are signs of urinary retention or output issues.
C. Checking the accuracy of the medication list is important for understanding the client's current treatment regimen and any possible drug interactions or errors. However, this action does not directly address the urgent symptoms of fever, nausea, vomiting, and blurred vision, which could be indicative of a more immediate medical issue.
D. Given the client’s history of insulin-dependent diabetes mellitus and the presenting symptoms, obtaining a capillary blood glucose level is the most critical and immediate intervention. The symptoms of fever, nausea, vomiting, and blurred vision can be associated with hyperglycemia (high blood glucose) or hypoglycemia (low blood glucose).

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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

The nurse prepares to instill an adolescent client's ear drops as seen in the picture. Which should the nurse do next?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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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?