When performing a focused gastrointestinal system assessment, the practical nurse (PN) asks a male client when his last bowel movement occurred. The client answers, "Three days ago." Which action should the PN implement first?

Administer a prescribed PRN stool softener

Determine the client's usual bowel patern

Encourage the client to ambulate more frequently

Recommend increasing high-fiber foods daily

Answer and Explanation

The Correct Answer is B

A bowel patern is the frequency, consistency, and appearance of a person's bowel movements. A normal bowel patern is what's normal for each person, and it can vary depending on factors such as diet, age, physical activity, and health conditions.
A focused gastrointestinal system assessment includes collecting subjective data about the patient's history of gastrointestinal disease, signs and symptoms of gastrointestinal problems, diet and nutrition, and bowel patern. It also includes inspecting and auscultating the abdomen for any abnormalities³.
When a client reports having a bowel movement three days ago, the first action that the practical nurse should implement is to determine the client's usual bowel patern. This will help to evaluate if the client is experiencing constipation or if this is their normal frequency. It will also help to identify any changes or risk factors that may aﬀect the client's bowel function.

Therefore, option B is the correct answer, while options A, C, and D are incorrect.

Option A is incorrect because administering a stool softener without assessing the client's bowel patern may not be appropriate or eﬀective.

Option C is incorrect because encouraging ambulation may help to stimulate bowel activity, but it is not the first action to take.

Option D is incorrect because recommending dietary changes may be helpful for preventing or treating constipation, but it is not the first action to take.

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Correct Answer is ["A","C","F"]

Explanation

Choice A rationale:

Urticaria is a skin condition characterized by the sudden appearance of raised, itchy, and red welts on the skin. It is an objective finding because it can be observed and assessed visually. The presence of urticaria may indicate an allergic reaction or another underlying condition.

Choice B rationale:

Hypertension is a subjective finding because it cannot be directly observed. It requires blood pressure measurement to confirm, making it a subjective parameter.

Choice C rationale:

Diaphoresis refers to excessive sweating, which can be observed and assessed visually. It is an objective finding and may be indicative of various conditions, including anxiety or fever.

Choice D rationale:

Nausea is a subjective symptom because it is a sensation that the client experiences and reports. It cannot be directly observed by the nurse, making it a subjective parameter.

Choice E rationale:

Anxiety is a subjective symptom, as it is a mental and emotional state experienced by the client. It cannot be directly observed, making it a subjective parameter.

Choice F rationale:

Edema is an objective finding because it can be visually assessed by the nurse. Edema is the accumulation of excess fluid in body tissues, and its presence or absence can be objectively determined.

A. Procure platelet products from the blood bank. B. Titrate oxygen to the prescribed parameters. C. Monitor an intravenous infusion rate on an established schedule. D. Insert a urinary catheter for an uncomplicated client.

Correct Answer is C

Explanation

Choice A rationale:

Procuring platelet products from the blood bank is a task that should be performed by a licensed nurse, not an unlicensed assistive personnel (UAP). It involves assessing the client's needs, verifying orders, and administering the product, which require nursing judgment and skills.

Choice B rationale:

Titrating oxygen to prescribed parameters is a nursing task that requires clinical judgment, especially if the client's condition changes. UAPs do not have the training or scope of practice to adjust oxygen levels. This task should be assigned to a licensed nurse.

Choice D rationale:

Inserting a urinary catheter, even for an uncomplicated client, is a task that should be performed by a licensed nurse. It involves the potential risk of infection and injury, and it requires sterile technique and assessment of the client's condition. UAPs do not have the training or scope of practice to insert urinary catheters.

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When performing a focused gastrointestinal system assessment, the practical nurse (PN) asks a male client when his last bowel movement occurred. The client answers, "Three days ago." Which action should the PN implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing a client, the nurse should establish which finding(s) as objective? (Select all that apply.).

Correct Answer is ["A","C","F"]

Explanation

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to an unlicensed assistive personnel (UAP)?

Correct Answer is C

Explanation

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