A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care?
Patient will have one soft, formed bowel movement by end of shift.
Patient will not take any pain medications this shift.
Patient will walk unassisted to bathroom by the end of shift.
Patient will be offered laxatives or stool softeners this shift.
The Correct Answer is A
A. This outcome is specific, measurable, and directly addresses the goal of managing constipation by aiming for a bowel movement.
B. Discontinuing pain medication abruptly may be unrealistic and can cause distress for the patient.
C. Ambulation may help with constipation but does not directly measure or ensure bowel movement.
D. Offering laxatives or stool softeners is an intervention rather than a measurable patient outcome.
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Correct Answer is D
Explanation
A. The superior vena cava is responsible for returning deoxygenated blood from the upper body to the heart and is not directly involved in myocardial ischemia.
B. The carotid artery supplies blood to the brain and is not the primary focus in the context of myocardial infarction.
C. The pulmonary artery carries deoxygenated blood from the heart to the lungs and is not involved in coronary circulation.
D. The coronary arteries supply blood to the heart muscle itself. Ischemia during a myocardial infarction occurs when these arteries are blocked or narrowed, leading to a lack of blood flow and oxygen to the heart tissue.
Correct Answer is C
Explanation
A. Continuing with the injection after seeing blood return increases the risk of injecting into a blood vessel, which is not safe for IM injections.
B. Administering at a slower rate does not address the issue of possible intravascular injection.
C. If blood is aspirated, the correct procedure is to withdraw the needle, dispose of the medication, and prepare a new dose to prevent intravascular administration, as IM injections are meant to be given into muscle tissue, not into a vein.
D. Pulling the needle back slightly is not recommended because it does not ensure that the needle is completely out of the blood vessel.