Answer to Question 1
3
Rationale: The nurse is aware that opioids cause constipation by slowing down the gastrointestinal system, and will assess bowel habits to determine the need for interventions to relieve constipation. Clients on long-term opioids might need a daily laxative. If the client is experiencing constipation, the nurse would then assess nutritional and exercise habits and suggest measures to help alleviate constipation. There is no evidence that this client has any issues creating a safety risk.
Answer to Question 2
3
Rationale: Not every client that the nurse is assigned will need help with ADLs. It is important to determine the level of assistance that each client needs before beginning care. Delegation to the UAP and collection of equipment cannot be done until the nurse determines how much help each client requires. The nurse does not tell the client the schedule for AM care, but asks the client if it would be convenient to receive AM care at this time.