Question 1:
A nurse is reinforcing teaching with a client who is postpartum and is taking
docusate sodium to prevent constipation. Which of the
... [Show More] following instructions
should the nurse include?
A. Take this medication every day for regular bowel movements.
B. Take the medication with mineral oil.
C. Decrease dietary fiber intake while taking this medication.
D. Take the medication with a full glass of water.
Show correct answer and explanation
Explanation
Choice A reason:
Take this medication every day for regular bowel movements. Rationale: This
choice is incorrect. Docusate sodium is a stool softener used to prevent
constipation, but it should not be taken daily for regular bowel movements.
Overuse of stool softeners can lead to dependence and may disrupt the natural
bowel function.
Choice B reason:
Take the medication with mineral oil. Rationale: This choice is incorrect. Docusate
sodium should not be taken with mineral oil. When taken together, they can form
a mixture that is difficult for the body to absorb, leading to potential adverse
effects.
Choice C reason:
Decrease dietary fiber intake while taking this medication. Rationale: This choice
is incorrect. It is not advisable to decrease dietary fiber intake while taking
docusate sodium. Fiber is essential for promoting regular bowel movements and
overall gastrointestinal health.
Combining the medication with a high-fiber diet can enhance its effectiveness.
Choice D reason:
Take the medication with a full glass of water. Rationale: This choice is correct.
The nurse should instruct the client to take docusate sodium with a full glass of
water. The water helps to soften the stool and allows the medication to work
effectively in preventing constipation.
Question 2:
A nurse is caring for a 9-year-old client who is immediately postoperative. The
client is nonverbal and has both cognitive and developmental delays. Which of
the following pain scales should the nurse use to evaluate the client's pain?
A. FACES Scale.
B. Numerical scale.
C. FLACC pain assessment scale.
D. Visual analog scale.
Show correct answer and explanation
Explanation
Choice A reason:
The FACES Scale is a visual pain scale typically used for children who can
understand and verbalize their pain intensity. It consists of a series of faces with
varying expressions, from smiling to crying, to help the child express their pain
level. However, since the client in question is nonverbal and has cognitive and
developmental delays, this scale may not be suitable as they might not be able
to communicate using this tool effectively.
Choice B reason:
The Numerical Scale involves asking the patient to rate their pain on a scale of 0
to 10, with 0 being no pain and 10 being the worst pain imaginable. While this
scale is commonly used for older children and adults, it may not be appropriate
for a nonverbal and developmentally delayed 9-year-old client, as they may not
understand or be able to use numbers effectively to express their pain.
Choice C reason:
The FLACC pain assessment scale is designed for nonverbal or preverbal
individuals, including children and those with cognitive impairments. FLACC
stands for Face, Legs, Activity, Cry, and Consolability. Each category is scored
from 0 to 2 or 0 to 3, depending on the version used, based on specific observed
behaviors. The scores are then totaled to give an overall pain assessment. This
scale is particularly suitable for the current client's condition as it focuses on
observable behaviors rather than verbal communication.
Choice D reason:
The Visual Analog Scale (VAS) requires the patient to mark a point along a line
that represents their pain intensity, with one end indicating no pain and the other
end indicating the worst pain. Although this scale is useful for older children and
adults, it may not be appropriate for a 9-year-old client with cognitive and
developmental delays who might not fully comprehend the concept of the scale.
Question 3:
A nurse is assisting with the care of a client who is receiving epidural
anesthesia for pain management during labor. Which of the following actions
should the nurse take?
A. Remind the client to void every 4 hr.
B. Encourage the client to alternate from side to side every 2 hr.
C. Raise the four side rails on the client's bed.
D. Monitor the client's blood pressure.
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Explanation [Show Less]