While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, solid, and light brown.
Which action should the nurse implement?

Wait to obtain the specimen until observable blood is present.

Withhold specimen collection until tarry black stool is observed.

Obtain the specimen from the client's current bowel movement.

Contact the healthcare provider before obtaining the specimen.

Answer and Explanation

The Correct Answer is C

Choice A Reason: This is incorrect because occult blood is not visible to the naked eye. Waiting for observable blood may delay diagnosis and treatment of gastrointestinal bleeding.

Choice B Reason: This is incorrect because tarry black stool indicates upper gastrointestinal bleeding, which may not be related to the client's condition. Occult blood can be present in any color of stool.

Choice C Reason: This is correct because the nurse should obtain the specimen from the client's current bowel movement, regardless of its color or consistency. The test for occult blood detects hemoglobin in the stool, which may indicate bleeding anywhere along the gastrointestinal tract.

Choice D Reason: This is incorrect because contacting the healthcare provider before obtaining the specimen is unnecessary and may waste time. The nurse should follow the protocol for stool specimen collection and report any abnormal findings to the provider.

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Correct Answer is C

Explanation

Choice A: Complete an adverse occurrence/incident report is not the most important action because it does not correct the immediate problem or prevent harm to the client. The nurse should report the incident after ensuring the safety and comfort of the client.
Choice B: Ensure that the restraints are not too tight is an important action, but it is not enough to address the issue of improper securing of the restraints. The nurse should also teach the UAP how to secure the restraints correctly and safely.
Choice C: Demonstrate proper securing of the restraints is the most important action because it educates the UAP and prevents potential complications such as injury, infection, or circulation impairment. The nurse should show the UAP how to secure the restraints to a movable part of the bed frame, not to the rails.
Choice D: Initiate the facility’s restraint flow sheet is an important action, but it is not urgent or critical in this situation. The nurse should document and monitor the use of restraints according to the facility’s policy, but only after ensuring that they are applied correctly and appropriately.

A. Provide comfort measures such as topical warm application and tactile massage. B. Assist the client to ambulate as much as possible during waking hours. C. Determine client's subjective measure of pain using a numerical pain scale. D. Encourage increased fluid intake and measure urinary output every 8 hours. E. Implement a 24-hour schedule of routine administration of prescribed analgesic.

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

Explanation

Choice A Reason: This is correct because providing comfort measures such as topical warm application and tactile massage can help reduce pain perception and promote relaxation by stimulating non-painful sensory receptors.

Choice B Reason: This is incorrect because assisting the client to ambulate as much as possible during waking hours can increase pain intensity and fatigue by aggravating inflamed or injured tissues. The nurse should encourage moderate physical activity within the client's tolerance level.

Choice C Reason: This is correct because determining client's subjective measure of pain using a numerical pain scale can help assess pain severity and effectiveness of pain management interventions. Pain is a subjective experience that varies among individuals.

Choice D Reason: This is incorrect because encouraging increased fluid intake and measuring urinary output every 8 hours are not directly related to pain management. These interventions are more relevant for clients with fluid imbalance or renal impairment.

Choice E Reason: This is correct because implementing a 24-hour schedule of routine administration of prescribed analgesic can help maintain a steady level of analgesia and prevent breakthrough pain. Chronic pain requires continuous treatment rather than on-demand administration.

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While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, solid, and light brown. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes the unlicensed assistive personnel (UAP) securing a client’s wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

Correct Answer is C

Explanation

After reviewing the admission assessment of a client with chronic pain, which intervention(s) should the nurse include in this client's plan of care? (Select all that apply.)

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

Explanation

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While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, solid, and light brown. Which action should the nurse implement?

A client with a family history of cardiac disease is seeking information to control risk factors. Which lifestyle modification is most important for the nurse to encourage?

While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, solid, and light brown.
Which action should the nurse implement?