a nurse is caring for a client who is constipated what intervention is most appropriate

ATI LPN

ATI NCLEX PN Predictor Test

1. A nurse is caring for a client who is constipated. What intervention is most appropriate?

A. Administer a laxative to relieve discomfort
B. Encourage the client to increase dietary fiber intake
C. Encourage the client to rest until symptoms resolve
D. Administer a stool softener as prescribed

Correct answer: B

Rationale: The most appropriate intervention for constipation is to encourage the client to increase dietary fiber intake. Fiber helps promote bowel movements and relieve constipation by adding bulk to the stool. Administering a laxative (Choice A) should not be the first-line intervention as it can lead to dependence. Encouraging rest (Choice C) is not directly helpful in relieving constipation. While administering a stool softener (Choice D) can be beneficial, increasing fiber intake is generally preferred as the initial intervention.

2. How should a healthcare professional assess and manage a patient with dehydration?

A. Assess skin turgor and monitor intake/output
B. Encourage oral fluids only
C. Administer IV fluids immediately
D. Check for electrolyte imbalance and administer fluids

Correct answer: A

Rationale: The correct way to assess and manage a patient with dehydration is to assess skin turgor and monitor intake/output. Skin turgor assessment helps in evaluating the degree of dehydration, while monitoring intake/output aids in maintaining fluid balance. Encouraging oral fluids only (Choice B) may not be sufficient for moderate to severe dehydration as patients may need intravenous fluids (IV) to rapidly rehydrate. Administering IV fluids immediately (Choice C) is not always the first step unless the patient is severely dehydrated. Checking for electrolyte imbalance and administering fluids (Choice D) is important but comes after assessing skin turgor and intake/output in the management of dehydration.

3. What are the signs of an acute myocardial infarction?

A. Chest pain radiating to the arm and shortness of breath
B. Nausea, vomiting, and high fever
C. Headache, confusion, and low blood pressure
D. Increased heart rate and bradycardia

Correct answer: A

Rationale: The correct answer is A: Chest pain radiating to the arm and shortness of breath. These are classic signs of an acute myocardial infarction. Choice B is incorrect because nausea, vomiting, and high fever are not typical signs of a heart attack. Choice C is incorrect as headache, confusion, and low blood pressure are not specific to myocardial infarction. Choice D is incorrect because an acute myocardial infarction typically presents with an increased heart rate, not bradycardia.

4. What are the signs of opioid withdrawal, and how should it be managed?

A. Sweating, nausea; administer methadone
B. Muscle cramps, vomiting; administer naloxone
C. Tremors, sweating; administer buprenorphine
D. Fever, agitation; provide sedatives

Correct answer: A

Rationale: The signs of opioid withdrawal typically include sweating and nausea. The correct management approach involves administering methadone to alleviate the symptoms. Choice B is incorrect because naloxone is used to reverse opioid overdose, not for managing withdrawal symptoms. Choice C is incorrect as buprenorphine is typically used to treat opioid addiction, not just withdrawal symptoms. Choice D is incorrect as sedatives are not the primary treatment for opioid withdrawal.

5. A client is receiving IV fluids and has developed phlebitis. What is the next step the nurse should take?

A. Monitor the site for further swelling
B. Remove the catheter and place it in another site
C. Reduce the flow rate of IV fluids
D. Switch to oral hydration

Correct answer: B

Rationale: The correct next step when a client develops phlebitis while receiving IV fluids is to remove the catheter and place it in another site. Phlebitis is inflammation of a vein, and leaving the catheter in the same site can lead to further complications. Monitoring the site for further swelling, as in choice A, is not enough as the source of inflammation needs to be removed. Choice C, reducing the flow rate, may not address the underlying issue causing phlebitis. Switching to oral hydration, as in choice D, is not necessary for addressing phlebitis related to IV fluid administration.