A client has not had a bowel movement in 2 days and reports this information to the nurse. Which intervention should the nurse implement first?
A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes.
B. Notify the HCP and request a prescription for a stool softener
C. Ass...
HESI NCLEX Practice Questions Answered Correctly
A client has not had a bowel movement in 2 days and reports this information to the nurse. Which intervention should the nurse implement first?
A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes. B. Notify the HCP and request a prescription for a stool softener
C. Assess the client's medical record to determine his normal bowel pattern.
D. Instruct the caregiver to increase the client's fluids to five 8 ounce glasses per day. - ANSWER
C. Assess the client's medical record to determine his normal bowel pattern.
Bowel movements vary per person. Some people go multiple times a day and others go a few times a week. The answer is an assessment, not an intervention.
A client who has chronic obstructive pulmonary disease (COPD) is resting in a semi-Fowler's position with oxygen at 2 L/min per nasal cannula. The client develops dyspnea. Which action should the nurse take first? A. Call the HCP
B. Obtain a bedside pulse oximeter
C. Raise the head of the bed higher
D. Assess the clients vital signs - ANSWER C. Raise the head of the bed higher
For COPD you want an SpO2 >90%. Fowler's position can help to open up the chest wall and aid in breathing. B and D are normally done in the same assessment so you can check those off.
A client who has hyperparathyroidism is scheduled to receive a prescribed dose of oral phosphate. The nurse notes that the client's serum calcium is 12.5 mg/dL. What action should the nurse take? A. Hold the phosphate and notify the HCP
B. Review the client's serum parathyroid hormone level
C. Give a PRN dose of IV calcium per protocol
D. Administer the dose of oral phosphate - ANSWER D. Administer the dose of oral phosphate A normal calcium level is 5.5-10.5 mg/dL so this value is high. Calcium and phosphate have an inverse reaction so in order to lower the calcium, there needs to be more phosphate. Giving the
oral phosphate will be beneficial to lowering the serum calcium level. In completing a client's perioperative routine, the nurse finds that the consent form has not been signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take? A. Witness the client's signature on the consent form
B. Answer the client's questions about the surgery
C. Inform the HCP that the client has questions about the surgery
D. Reassure the client that the surgeon will answer any questions before the anesthetic is administered - ANSWER C. Inform the HCP that the client has questions about the surgery
The nurse has to witness the surgery in person but because the client has questions, informed consent is not given. The nurse cannot answer questions about the surgery because that is the HCP's responsibility. If the HCP does not know about questions, they may not answer them before the surgery.
The unlicensed assistive personnel (UAP) reports to the staff nurse that a client who had surgery 4 hours ago has a decrease in blood pressure (BP), from 150/80 to 110/70, in the past hour. The nurse advises the UAP to check the client's dressings for excess drainage and report the findings to the nurse. Which factor is most important to consider when assessing the legal ramifications of this situation? A. The parameters of the state's or province's nurse practice act
B. The need to complete an adverse occurrence report
C. Hospital protocol regarding the frequency of vital sign assessment every hour postoperatively D. The healthcare provider's prescription for changing the postoperative dressing - ANSWER A. The parameters of the state's or provinces nurse practice act
The nurse asked the UAP to perform a task that is outside of their scope of practice. This is states in the Nurse Practice Act for the state or province.
The newly licensed nurse overhears two nurses talking in the elevator about a client who will lose her leg because of negligence of the staff. Which action by the newly licensed nurse should
be implemented first? A. Monitor the nurses closely for further occurrences
B. Advise them to cease their communication
C. Inform the nurse manager of the conversation
D. Submit an occurrence or variance report - ANSWER B. Advise them to cease their communication
This is a HIPPA violation and needs to be addressed presently. The new nurse should tell them to talk privately or not at all about the case. If they continue the conversation the nurse should
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller NursingTutor1. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $14.99. You're not tied to anything after your purchase.
