Bowel Elimination
A postoperative patient has not had a bowel movement in 3 days but is passing flatus. The priority nursing action is this.
What is encourage ambulation and fluids (if not contraindicated)?
The best indicator that a patient is not tolerating activity.
What is shortness of breath or abnormal vital sign response?
The process of assigning a task to another team member while retaining responsibility for the outcome is called this.
What is delegation?
The ability to be fully attentive and emotionally available to a patient in the moment is called this.
What is presence?
Screening blood pressure annually represents this level of prevention.
What is secondary prevention?
A patient reports sudden severe abdominal pain, rigid abdomen, and absent bowel sounds. The nurse suspects this complication.
What is bowel obstruction or perforation?
The safest way for a nurse to protect their back when moving a patient is this.
What is use proper body mechanics?
An AP reports a BP of 84/50. The nurse’s FIRST responsibility is this.
What is reassess the patient?
A patient refuses ambulation after surgery. The nurse should first do this.
What is explore the patient’s concerns?
Teaching the DASH diet to a newly diagnosed hypertensive patient represents this level of prevention.
What is primary prevention?
An older adult with chronic constipation begins having liquid stool leakage. The nurse should suspect this.
What is fecal impaction?
Range-of-motion exercises primarily help maintain this.
What is joint flexibility?
The “Right Task, Right Person, Right Circumstance, Right Direction, and Right Supervision” are known collectively as this.
What are the Five Rights of Delegation?
Before using touch in a clinical setting, the nurse should first assess this.
What is the patient’s comfort level (or cultural preference)?
Stroke rehabilitation services represent this level of prevention.
What is tertiary prevention?
A patient with C. diff has frequent watery stools. The nurse’s priority action is this.
What is initiate contact precautions?
A patient with right-sided weakness is learning to transfer from bed to chair. The nurse should place the wheelchair on this side of the bed.
What is the stronger side?
When managing care for multiple patients, the nurse should prioritize using this framework.
What is ABCs (Airway, Breathing, Circulation)?
This caring behavior supports safety and clinical reasoning.
What is knowing the patient’s baseline?
A patient states, “I feel fine. I don’t need to change my diet.” This Health Belief Model concept is lacking.
What is perceived susceptibility or severity?
A patient receiving opioids develops hypoactive bowel sounds and abdominal distention. The nurse’s FIRST action is this.
What is assess for opioid-induced constipation and intervene (stool softener, ambulation, fluids)?
When assisting a patient to stand, the nurse should position their feet in this way for stability.
What is shoulder-width apart?
A nurse fails to follow up after delegating vital signs. This professional principle is violated.
What is accountability?
A patient is tearful after receiving a new diagnosis.
The most appropriate demonstration of therapeutic presence is this.
What is sit at eye level and allow silence?
The most effective strategy to evaluate learning during discharge teaching.
What is teach-back?