The nurse is providing postoperative teaching to a client on ways to prevent constipation. Which information should the nurse include?

Drink 800 to 1,000 milliliters of fluid daily.

Take oxycodone as scheduled to prevent painful bowel movements.

Add fat-containing foods in the diet to lubricate stools for easier passage.

Ambulate early and as frequently as possible.

Answer and Explanation

The Correct Answer is D

Choice A reason: Drinking 800 to 1,000 milliliters of fluid daily is below the recommended intake for most adults, which is generally around 2,000 milliliters per day to help prevent constipation.

Choice B reason: Oxycodone is an opioid that can actually lead to constipation, and its use should be carefully managed, not necessarily taken as scheduled for this purpose.

Choice C reason: Adding fat-containing foods is not a standard recommendation for preventing constipation; instead, a high-fiber diet is usually advised.

Choice D reason: Early and frequent ambulation is encouraged postoperatively to help stimulate bowel function and prevent constipation.

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Correct Answer is D

Explanation

Choice A reason: While the client's medical history and admission assessment provide valuable information, they do not directly measure the current pain experience.

Choice B reason: Vital signs can indicate pain but are not a definitive measure of pain severity as they can be influenced by other factors.

Choice C reason: The frequency of analgesic administration may suggest the level of pain control but does not measure the current pain intensity experienced by the client.

Choice D reason: Asking the client to describe the intensity of the pain is the most direct and effective way to assess pain severity. Pain is subjective, and the client's self-report is considered the gold standard for pain assessment.

A. Reduce the amount of pressure being applied on the top of the foot. B. Document in the nurse's notes that the dorsalis pedis pulse is not palpable. C. Obtain a Doppler stethoscope to auscultate the pulse at the same site. D. Palpate the site on the inner side of the ankle below the medial malleolus.

Correct Answer is C

Explanation

Choice A reason: Reducing the amount of pressure may not be effective if the pulse is weak or absent; other methods may be needed to assess circulation.

Choice B reason: Documentation is important, but it should be done after all attempts to assess the pulse have been made.

Choice C reason: Using a Doppler stethoscope is a suitable next step when a pulse is not palpable, as it can detect weaker pulses not felt by palpation.

Choice D reason: Palpating the site on the inner side of the ankle below the medial malleolus assesses the posterior tibial pulse, not the dorsalis pedis pulse.

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The nurse is providing postoperative teaching to a client on ways to prevent constipation. Which information should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?

Correct Answer is D

Explanation

To assess a client's dorsalis pedis pulse, the nurse applies firm pressure over the top of the foot between the extension tendons of the great and first toes but does not feel a pulsation. Which action should the nurse take next?

Correct Answer is C

Explanation

The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style of shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?

A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger widths between the top of the crutch and the client's axilla. Which action should the nurse take?

The nurse is explaining perineal care to the caregiver of a male client. Which information should the nurse include?

The nurse assesses an adult client with a partial rebreather mask and notes that the oxygen reservoir bag does not deflate completely during respiration and the client's respiratory rate is 14 breaths/minute. Which action should the nurse implement?

The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

An older adult client returns to the clinic for chronic pain management after taking morphine sulfate 25 mg PO every 12 hours. The client reports taking the medication only when the pain was too severe to sleep. Which action should the nurse implement?