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 C
Explanation
A. Atelectasis can occur in anyone, not just those with chronic conditions; this statement is incorrect.
B. While hyperventilation may temporarily open alveoli, it is not a preventative measure for atelectasis.
C. Breathing exercises, such as incentive spirometry or deep breathing, are effective in preventing atelectasis by promoting lung expansion and alveolar ventilation.
D. A chest tube is typically used to remove air or fluid from the pleural space, not for the treatment of atelectasis, which is often managed with respiratory therapies.
Correct Answer is B
Explanation
A. A patient with hypercapnia requires monitoring, but wearing an oxygen mask indicates some level of intervention is in place.
B. A patient with a chest tube should never ambulate with the chest tube unclamped, as this can lead to a collapsed lung and respiratory distress; thus, this patient should be prioritized.
C. While a patient with thick secretions may need suctioning, this is not as critical as ensuring the safety of a patient with an unclamped chest tube.
D. A patient with a new tracheostomy requires monitoring, but the presence of the obturator indicates readiness for emergencies; this does not take priority over the safety of the patient with the chest tube.