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The nurse observes that Joan's abdomen is firm and distended. The nurse performs an abdominal assessment. In what sequence should the nurse perform the abdominal assessment? -Auscultation, inspection, percussion, palpation. -Inspection, palpation, auscultation, percussion. -Inspection, auscultation, percussion, palpation. -Auscultation, percussion, inspection, palpation. - correct answer ✅Inspection, Auscultation, Percussion, Palpation Rationale: Percussion and palpation can alter abdominal findings, so inspection and auscultation are indicated prior to percussion and palpation. Which assessment is most important for the nurse to perform? -Auscultate bowel sounds -Measure abdominal girth -Observe incisional staples -Measure blood pressure - correct answer ✅Auscultate bowel sounds. Rationale:
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The subjective data reported by the client (bloated and nauseated) and objective data gathered by the nurse (abdomen firm and distended) suggest that she may have decreased peristalsis. This can be assessed by auscultation of the bowel sounds. Which is the most important action for the nurse to perform when assessing bowel sounds? (Select all that apply.) -Ask the client if she has lost or gained any weight. -Listen for up to 5 minutes when auscultating for bowel sounds. -Perform a rectal exam. -Inspect the client's abdomen while she is in a semi-Fowler's position. -Begin auscultation in the right lower quadrant. - correct answer ✅-Listen for up to 5 minutes when auscultating for bowel sounds. Rationale: The nurse must listen for up to 5 minutes before determining what type of bowel sounds are present. The nurse should auscultate in the right lower quadrant, and then proceed to the other quadrants. -Begin auscultation in the right lower quadrant. Rationale: The nurse should auscultate in the right lower quadrant, and then proceed to the other quadrants. The nurse must listen for up to 5 minutes before determining what type of bowel sounds are present. The nurse auscultates for Joan's bowel sounds and hears faint gurgling sounds after 3 minutes. Which assessment finding should the nurse document?
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Which response by the nurse will encourage continued verbalization by the client? -All of the nurses are very busy here, and they are doing the best job they can. -You should write down your questions so you can get some answers. -I will be happy to tell you everything that's happening, so nothing else will go wrong. -It sounds as if you have had another experience that did not go well. - correct answer ✅"It sounds as if you have had another experience that did not go well." Rationale: The nurse's response validates Joan's feelings, which will encourage Joan to verbalize further. The nurse informs the client that she has developed constipation. The client tells the nurse that she hates hospitals because nobody ever tells you what's happening, and you end up with all these things going wrong. The client continues and states that she did everything her healthcare provider (HCP) told her to do. The client is convinced that the surgery must caused this and that they must have made a mistake in surgery. Which explanation by the nurse is accurate? -Refer the client to the surgeon to answer any questions about the surgical outcome. -Advise the client that an abdominal hysterectomy should not cause decreased peristalsis, so an error must have occurred during surgery.
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-Offer the client emotional support as she copes with this adverse outcome of surgery. -Explain to the client the multiple factors that can decrease peristalsis postoperatively, even when the desired surgical outcome is achieved. - correct answer ✅Explain to the client the multiple factors that can decrease peristalsis postoperatively, even when desired surgical outcome is achieved. Rationale: Constipation secondary to decreased peristalsis postoperatively is not considered a poor surgical outcome. Multiple factors surrounding abdominal surgery can lead to decreased peristalsis. Which postoperative medication is most likely to contribute to constipation? -Morphine sulfate, an opioid analgesic. -Ibuprofen, a non-opioid analgesic. -Promethazine, an antiemetic. -Cefazolin, an antibiotic. - correct answer ✅Morphine sulfate, an opioid analgesic. Rationale:The most common adverse effect of opioid analgesics is constipation. The nurse instructs the client on which activity that would minimize risk for constipation? -Getting out of bed and ambulating. -Regular use of the incentive spirometer.
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-Supine. -Prone. -Sim's. - correct answer ✅Sim's Rationale: The client should be in left side-lying Sim's position, with the knee flexed. When administering the rectal suppository, the nurse asks the client to take several slow, deep breaths. What is the rationale for this instruction? -Distract her from the suppository insertion. -Relax the anal sphincter and reduce discomfort. -Improve intestinal peristalsis and motility. -Reduce spasms from any hemorrhoids. - correct answer ✅Relax the anal sphincter and reduce discomfort Rationale: Deep breathing promotes relaxation of the anal sphincter, thereby reducing discomfort when the suppository is inserted. After administering the rectal suppository, how should the nurse document this action? -0900. Lubricant used when one bisacodyl suppository inserted. -0900. One suppository inserted because of constipation. -0900. One bisacodyl suppository administered per rectum for constipation, as prescribed.
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-0900. One bisacodyl administered for constipation. - correct answer ✅900. One bisacodyl suppository administered per rectum for constipation, as prescribed. Rationale: This documentation correctly identifies the medication, the dose, the time, and the route of administration, as well as the reason for administering the medication. Which statement provides the best documentation of the outcome from the suppository administration? -1100. Client reports that the suppository was not helpful in relieving constipation. -1100. Client reports producing six, 0.25 inch, hard pellets of brown stool following suppository administration. -1100. Client will need additional treatment to resolve problem of constipation. -1100. Suppository administration produced only a small amount of feces. - correct answer ✅1100. Client reports producing six, 0.25 inch, hard pellets of brown stool following suppository administration. Rationale: This documentation provides the most specific objective data related to the effectiveness of the suppository. Reduction of Risk Potential The next day, the client still has not expelled additional feces.
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-Ask the UAP to assist with client positioning while the nurse performs the procedure, while teaching the UAP about the correct supplies needed. - correct answer ✅Ask the UAP to assist with client positioning while the nurse performs the procedure, while teaching the UAP about the correct supplies needed. Rationale: The task should not be delegated to the UAP because it is an invasive procedure that places the client at risk. The UAP can be assigned to assist the nurse with client positioning. Assisting in this manner provides an opportunity for the nurse to teach the UAP that this is not a sterile procedure. The nurse should use nonsterile gloves, which are less costly than sterile gloves, and lubricant for this procedure. While performing the digital rectal exam, the nurse recognizes that the client may experience vagal nerve stimulation. This can result in which change in vital signs? -Increased blood pressure. -Increased temperature. -Decreased respirations. -Decreased pulse rate. - correct answer ✅Decreased pulse rate. Rationale: Vagal nerve stimulation can cause a reflex slowing of the heart rate. Management of Care
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The nurse notifies the HCP of the presence of a fecal impaction and receives a verbal prescription over the telephone for soap suds enema administration. When receiving the verbal prescription over the telephone, the nurse repeats the prescription back to the healthcare provider, who sounds angry and states, "Are you questioning my prescription?" How should the nurse respond to the healthcare provider? -Make sure you sign this verbal prescription within 24 hours. -I want to ensure that I transcribe this prescription correctly to avoid error. -You should be glad I want to ensure the accuracy of this prescription. -I have the responsibility to question any prescriptions I do not feel are correct - correct answer ✅"I want to ensure that I transcribe this prescription correctly to avoid error." Rationale: This assertive response teaches the healthcare provider the purpose of repeating back verbal prescriptions. What action should the nurse implement? -Wait to administer the enema until the HCP is able to sign the prescription in person. -Administer the enema as prescribed and obtain the HCP's signature the next day. -Explain to the HCP that verbal prescriptions are not legally defensible, and a written prescription is needed.
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-Roll the clamp to stop the enema until cramping subsides. Rationale: This action will stop or slow down cramping. When cramping decreases, start enema again by slowly releasing the clamp to begin flow. Math The client informs the nurse she is interested in the amount of fluid administered via the enema but does not understand milliliters. The client received a total volume of 725 mL. How will the nurse accurately explain the amount of fluid to Joan using household measurements? -3 cups. -6 cups. -1 quart. -1/2 gallon. - correct answer ✅3 cups. Rationale: The conversion factors needed are: 30 ml = 1 ounce, and 1 cup = 8 ounces. 725 ml/30 = 24 ounces/8 = 3 cups. The nurse encourages the client to increase her daily oral fluid intake to 2 liters of fluid for the next few days. This is equivalent to how many 8-ounce cups of fluid daily? -Four -Six
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-Eight -Ten - correct answer ✅Eight to nine Rationale: 1 ounce = 30mLOne 8-ounce cup contains - 8 x 30mL = 240mLTwo liters = 2, mL2,000 mL/240 mL = 8.33 cups/day. Health Promotion and Maintenance The remainder of the client's surgical recovery is uneventful. She continues to drink plenty of fluids, increases her activity, and has regular bowel movements. She eats a regular diet with no restrictions and asks the nurse about foods that promote bowel regularity. Which type of foods should the nurse recommend? -With fiber. -With Low sodium. -Low in carbohydrates. -With high protein. - correct answer ✅With fiber. Rationale: Foods with fiber accelerate the passage of food through the intestines, which is important for bowel regularity. The nurse uses the hospital breakfast menu as a teaching tool.
