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A nurse in an acute care facility is caring for a client who is postop following abdominal surgery. Which behavior should the nurse identify as increasing the client's risk for constipation?
- A. Increased physical activity
- B. Frequent urge suppression
- C. Increased fiber intake
- D. Decreased fluid intake
Correct Answer: B
Rationale: Frequent urge suppression can lead to constipation, especially postoperatively. Suppressing the urge to defecate can disrupt normal bowel movements and result in constipation. Increased physical activity, increased fiber intake, and adequate fluid intake are measures that typically help prevent constipation by promoting bowel regularity and preventing stool hardening. Therefore, choices A, C, and D are not behaviors that increase the client's risk for constipation.
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A nurse is caring for a client who is postop following abdominal surgery. What behavior should the nurse identify as increasing the client's risk for constipation?
- A. Increased fiber intake
- B. Decreased physical activity
- C. Frequent urge suppression
- D. Adequate sleep
Correct Answer: B
Rationale: The correct answer is B: Decreased physical activity. Following abdominal surgery, reduced physical activity can contribute to constipation due to decreased bowel motility. Increased fiber intake (choice A) generally helps prevent constipation by adding bulk to the stool. Frequent urge suppression (choice C) may lead to issues like urinary retention but is not directly linked to constipation. Adequate sleep (choice D) is important for overall recovery but does not significantly impact constipation risk.
A nurse is reviewing a client's health history and identifies chronic constipation as a potential complication of immobility. What intervention should the nurse include in the plan of care?
- A. Increase fiber intake
- B. Encourage the client to walk daily
- C. Use a stool softener as needed
- D. Use a laxative daily
Correct Answer: A
Rationale: Increasing fiber intake is the appropriate intervention to include in the plan of care for a client with chronic constipation due to immobility. Fiber helps add bulk to the stool, making it easier to pass, thereby preventing constipation. Encouraging the client to walk daily (choice B) is also beneficial as it promotes mobility and can help alleviate constipation associated with immobility. Using a stool softener as needed (choice C) and using a laxative daily (choice D) are not the first-line interventions for managing constipation related to immobility. Stool softeners and laxatives should be used judiciously and under healthcare provider guidance.
A nurse is assessing a client who has been receiving intermittent enteral feedings. What should the nurse identify as an intolerance to the feeding?
- A. Nausea
- B. Decreased heart rate
- C. Weight gain
- D. Fever
Correct Answer: A
Rationale: Nausea is a common symptom of intolerance to enteral feedings. When a client experiences nausea during enteral feeding, it can indicate issues such as feeding tube placement problems, formula intolerance, or gastroparesis. Nausea can lead to vomiting and further complications if not addressed promptly. Decreased heart rate, weight gain, and fever are not typically associated with intolerance to enteral feedings and would not be the primary indicators for this situation.
A nurse is reviewing the lab report of a client who has been experiencing a fever for the last 3 days. What lab result indicates the client is experiencing fluid volume deficit (FVD)?
- A. Decreased BUN levels
- B. Increased hematocrit
- C. Increased white blood cell count
- D. Decreased hematocrit
Correct Answer: B
Rationale: The correct answer is B: Increased hematocrit. Increased hematocrit indicates hemoconcentration, which is a sign of fluid volume deficit. When there is a decrease in fluid volume in the body, the blood becomes more concentrated, leading to an increase in hematocrit levels. Choices A, C, and D are incorrect because decreased BUN levels, increased white blood cell count, and decreased hematocrit are not indicative of fluid volume deficit.
A nurse is preparing to administer medications to a client through a nasogastric (NG) tube. Which action should the nurse take?
- A. Crush all the medications and mix them together in water
- B. Flush the NG tube with 10 mL of air before each medication
- C. Dissolve each medication separately and flush with water between medications
- D. Administer all medications at the same time
Correct Answer: C
Rationale: The correct action for the nurse to take when administering medications through an NG tube is to dissolve each medication separately and flush with water between medications. This practice helps prevent interactions between medications and ensures that each medication is delivered effectively. Option A is incorrect as mixing all medications together can lead to chemical interactions or alter the effectiveness of the medications. Option B is incorrect because flushing the NG tube with air is not recommended and may cause harm. Option D is incorrect as administering all medications at the same time does not allow for proper absorption and interaction control.