Question

1. The nurse is suggesting interventions for a client with chronic constipation. In which order should the nurse make these recommendations? Place then in order from 1^strecommendation to last recommendation.

1. Docusate.
2. Enema.
3. Increase fiber intake.
4. Bisacodyl.
5. Prune Juice.

2. A nurse observes this rash while assessing an infant, recognizing that it is a result of urinary incontinence. What intervention whould be added to the plan of care

1. Leave the skin open to air as much as possible
2. Apply lubricant jelly to the site three times each day
3. Obtain a prescription for an antibiotic ointment
4. Apply a cortisone cream

3. The nurse is caring for a client with a poor appetite, nausea and abdominal distention. What should the nurse anticipate upon auscultation of the abdomen?

1. Hyperactivity throughout
2. Normal sounds
3. Tympanic sounds
4. Diminished throughout

4. The nurse is caring for an older adult client with renal insufficiency. Vitals include temperature 99.8 F (37.6 C), heart rate 96, respirations 28, and BP 170/90 (117) mmHg. The client is restless, dyspneic, and anxious. The oxygen saturation drops to 87% when he pulls his oxygen cannula off. Which action should the nurse take after reapplying the oxygen?

1. Administer an anti-anxiety medication
2. Auscultate the lung sounds
3. Check recent labs
4. Administer an anti-hypertensive medication

5. An older adult female client reports a recent problem with urine hesitancy, decreased force of the flow, a sensation of incomplete emptying of the bladder, and dribbling. Which question should the nurse ask next?

1. Have you had flank pain?
2. Have you experienced abdominal pain?
3. Have you had a daily bowel movement?
4. Have you noticed if it’s worse at night?

Answer 1

1.Order of intervention for chronic constipation is as follows:

Increase fibre intake: It allows more water to remain in stool. Also it add bulk to stool

Prune juice: has 6.1 g of sorbital per 100g of juice. It has laxative effect.

Bisacodyl: it is a stimulant. It cause intestine to contract

Docusate: It is a stool softner. It acts by drawing water from intestine.

Enema; They soften stool and produce bowel movement.

2.The rash is most likely to be Incontinent associated dermatitis. Intervention added to plan of care :

b apply lubricant jelly to site 3 times each a day.

Here, use gentle dressings to clean the area. Wash the area with cleanser that balanced skin ph.

3.Here patient presents with poor appetite, nausea and abdominal distension. So most likely it is to be Intestinal obstruction.

a. Hyperactivity throughout.

On auscultation the bowel sounds will be Increased in frequency, pitch and volume.

4.b.auscultate lung fields.

Here when patient takes off his oxygen canula the saturation drops to 87%.

So first step here is put the oxygen canula first.

Then confirm the adequate ventilation of lungs by auscultating and moniter the improvement in saturation.

5.Here the question nurse to ask next is

d have you noticed if it's worse at night .

Urinary retention can be due to obstructive or non obstructive causes.

If there is obstruction: urine cannot flow freely through urinary tract.

If there is no obstruction : It can be due to weak bladder muscle and nerve problem that interfere with signals between brain and bladder.

If more symptoms at night then it might be more of neurogenic causes.