ATI Monroe college NY PN 23NS SP 126 exam 3
ATI Monroe college NY PN 23NS SP 126 exam 3 ( 25 Questions)
A nurse is contributing to the plan of care of a client who has a small bowel obstruction. Which of the following interventions should the nurse include?
Choice A: Provide bulk-forming agent. This is incorrect because bulk-forming agents are used to treat constipation, not bowel obstruction. They can worsen the obstruction by increasing the stool volume and pressure in the bowel.
Choice B: Elevate the head of the bed. This is incorrect because elevating the head of the bed does not directly affect the bowel obstruction. It may help with respiratory comfort, but it is not a priority intervention.
Choice C: Measure abdominal girth daily. This is correct because measuring abdominal girth daily can help monitor the progression of the bowel obstruction and the effectiveness of the treatment. An increase in abdominal girth may indicate worsening obstruction, distension, or perforation, while a decrease may indicate resolution or relief of the obstruction.
Choice D: Monitor intake and output every 8 hr. This is incorrect because monitoring intake and output is not enough to assess the fluid and electrolyte balance of a client with a bowel obstruction. The nurse should monitor intake and output more frequently, such as every 4 hr or every shift, and report any signs of dehydration or imbalance.
Choice A: Provide bulk-forming agent. This is incorrect because bulk-forming agents are used to treat constipation, not bowel obstruction. They can worsen the obstruction by increasing the stool volume and pressure in the bowel.
Choice B: Elevate the head of the bed. This is incorrect because elevating the head of the bed does not directly affect the bowel obstruction. It may help with respiratory comfort, but it is not a priority intervention.
Choice D: Monitor intake and output every 8 hr. This is incorrect because monitoring intake and output is not enough to assess the fluid and electrolyte balance of a client with a bowel obstruction. The nurse should monitor intake and output more frequently, such as every 4 hr or every shift, and report any signs of dehydration or imbalance.
Choice C: Measure abdominal girth daily. This is correct because measuring abdominal girth daily can help monitor the progression of the bowel obstruction and the effectiveness of the treatment. An increase in abdominal girth may indicate worsening obstruction, distension, or perforation, while a decrease may indicate resolution or relief of the obstruction.