Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assisting in the plan of care for a client who has constipation after receiving opioid medication for incisional pain. Which of the following actions should the nurse take first?
A. Auscultate the client's abdomen for bowel sounds.
Auscultate the client's abdomen for bowel sounds. This is the first action the nurse should take because it provides information about the client's bowel motility and function. Opioid medications can decrease bowel motility and cause constipation. The nurse should assess the client's abdomen before implementing any interventions.
B. Provide the client privacy with a set time to defecate.
Choice B is not correct because providing privacy and a set time to defecate is a nonpharmacological intervention that can help prevent constipation, but it is not the first action the nurse should take.
C. Administer a fiber-based laxative to the client.
Choice C is not correct because administering a fiber-based laxative is a pharmacological intervention that can help treat constipation, but it is not the first action the nurse should take. The nurse should also consider the client's fluid intake and preference before giving a laxative.
D. Encourage the client to increase oral intake of fluids.
Choice D is not correct because encouraging the client to increase oral intake of fluids is a nonpharmacological intervention that can help prevent constipation, but it is not the first action the nurse should take. The nurse should also consider the client's fluid balance and medical condition before giving fluids.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Adult Med Surg 2020 with NGN Proctored Exam. Take the full exam now
Full Explanation
The correct answer is choice A. Auscultate the client's abdomen for bowel sounds. This is the first action the nurse should take because it provides information about the client's bowel motility and function. Opioid medications can decrease bowel motility and cause constipation. The nurse should assess the client's abdomen before implementing any interventions.
- Choice B is not correct because providing privacy and a set time to defecate is a nonpharmacological intervention that can help prevent constipation, but it is not the first action the nurse should take.
- Choice C is not correct because administering a fiber-based laxative is a pharmacological intervention that can help treat constipation, but it is not the first action the nurse should take. The nurse should also consider the client's fluid intake and preference before giving a laxative.
- Choice D is not correct because encouraging the client to increase oral intake of fluids is a nonpharmacological intervention that can help prevent constipation, but it is not the first action the nurse should take. The nurse should also consider the client's fluid balance and medical condition before giving fluids.
Similar Questions
A nurse is reinforcing teaching with the partner of a client who has contact precautions in place for methicillin-resistant Staphylococcus aureus (MRSA).
Which of the following statements by the client's partner indicates an understanding of the teaching?
A. "I will wash my hands as soon as I leave the room."
Washing hands after leaving the room is an important infection control measure for individuals who come into contact with clients on contact precautions.
B. "I will wear a gown when I help my partner take a bath."
is incorrect because gowns are only necessary when there is a risk of contact with the client's body fluids
C. "I can reuse unsoiled gloves when I re-enter the room."
Choice C is incorrect because gloves should not be reused.
D. "I can take my partner outside of the room as long as they wear a mask."
Choice D is incorrect because the client should not leave the room while on contact precautions.
Full Explanation
The correct answer is choice A. Washing hands after leaving the room is an important infection control measure for individuals who come into contact with clients on contact precautions. Choice B is incorrect because gowns are only necessary when there is a risk of contact with the client's body fluids. Choice C is incorrect because gloves should not be reused. Choice D is incorrect because the client should not leave the room while on contact precautions. Choice B is not correct because gowns are only necessary when there is a risk of contact with the client's body fluids. Choice C is not correct because gloves should not be reused. Choice D is not correct because the client should not leave the room while on contact precautions.
A nurse is providing care for a client who has hemophilia and is bleeding from a small laceration on his arm. After applying a sterile dressing, which of the following actions should the nurse take next?
A. Maintain direct pressure over the site.
This is the most important initial step in controlling bleeding for any patient, especially one with hemophilia who has a deficiency in clotting factors. Maintaining pressure directly on the wound helps to form a clot and stop the bleeding.
B. Check whether the bleeding has stopped.
While checking for bleeding cessation is important, it shouldn't be the immediate next step after applying a dressing. Maintaining pressure ensures the dressing remains effective. Once pressure is released, you can assess for continued bleeding.
C. Obtain a radial pulse.
Assessing the radial pulse is not directly related to managing the bleeding from the laceration. While it's a vital sign, it's not a priority in this situation.
D. Reinforce the dressing over the site.
While reinforcing the dressing might be necessary later if it becomes saturated with blood, maintaining direct pressure is the crucial first step.
Full Explanation
The correct answer is: Choice A: Maintain direct pressure over the site.
Here's the rationale for each choice:
- Choice A: Maintain direct pressure over the site (CORRECT) This is the most important initial step in controlling bleeding for any patient, especially one with hemophilia who has a deficiency in clotting factors. Maintaining pressure directly on the wound helps to form a clot and stop the bleeding.
- Choice B: Check whether the bleeding has stopped While checking for bleeding cessation is important, it shouldn't be the immediate next step after applying a dressing. Maintaining pressure ensures the dressing remains effective. Once pressure is released, you can assess for continued bleeding.
- Choice C: Obtain a radial pulse Assessing the radial pulse is not directly related to managing the bleeding from the laceration. While it's a vital sign, it's not a priority in this situation.
- Choice D: Reinforce the dressing over the site While reinforcing the dressing might be necessary later if it becomes saturated with blood, maintaining direct pressure is the crucial first step.
A nurse is reinforcing teaching about liquid iron supplements with a client who has anemia. Which of the following information should the nurse include in the teaching?
A. Take iron supplements between meals for maximum absorption.
. The nurse should instruct the client to take iron supplements between meals for maximum absorption.
B. Reduce gastric distress by taking iron supplements with an antacid.
is incorrect because antacids can decrease absorption of iron
C. Check for orange-colored stools after 4 days of treatment.
is incorrect because orange-colored stools may occur after the first dose of iron
D. Mix iron supplements with milk to prevent staining of the teeth.
is incorrect because milk can also decrease absorption of iron
Full Explanation
The correct answer is choice A. The nurse should instruct the client to take iron supplements between meals for maximum absorption. Choice B is incorrect because antacids can decrease the absorption of iron. Choice C is incorrect because orange-colored stools may occur after the first dose of iron. Choice D is incorrect because milk can also decrease the absorption of iron. Choice B is not correct because antacids can decrease the absorption of iron. Choice C is not correct because orange-colored stools may occur after the first dose of iron. Choice D is not correct because milk can also decrease the absorption of iron.