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The nurse observes that Joan's abdomen is firm and distended. The nurse performs an abdominal assessment. In what sequence should the nurse perform the abdominal assessment? -Auscultation, inspection, percussion, palpation. -Inspection, palpation, auscultation, percussion. -Inspection, auscultation, percussion, palpation. -Auscultation, percussion, inspection, palpation. - correct answer ✅Inspection, Auscultation, Percussion, Palpation Rationale: Percussion and palpation can alter abdominal findings, so inspection and auscultation are indicated prior to percussion and palpation. Which assessment is most important for the nurse to perform? -Auscultate bowel sounds -Measure abdominal girth -Observe incisional staples -Measure blood pressure - correct answer ✅Auscultate bowel sounds. Rationale:
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The subjective data reported by the client (bloated and nauseated) and objective data gathered by the nurse (abdomen firm and distended) suggest that she may have decreased peristalsis. This can be assessed by auscultation of the bowel sounds. Which is the most important action for the nurse to perform when assessing bowel sounds? (Select all that apply.) -Ask the client if she has lost or gained any weight. -Listen for up to 5 minutes when auscultating for bowel sounds. -Perform a rectal exam. -Inspect the client's abdomen while she is in a semi-Fowler's position. -Begin auscultation in the right lower quadrant. - correct answer ✅-Listen for up to 5 minutes when auscultating for bowel sounds. Rationale: The nurse must listen for up to 5 minutes before determining what type of bowel sounds are present. The nurse should auscultate in the right lower quadrant, and then proceed to the other quadrants. -Begin auscultation in the right lower quadrant. Rationale: The nurse should auscultate in the right lower quadrant, and then proceed to the other quadrants. The nurse must listen for up to 5 minutes before determining what type of bowel sounds are present.
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Rationale: This open-ended statement encourages the client to express further concerns and fears. Which response by the nurse will encourage continued verbalization by the client? -All of the nurses are very busy here, and they are doing the best job they can. -You should write down your questions so you can get some answers. -I will be happy to tell you everything that's happening, so nothing else will go wrong. -It sounds as if you have had another experience that did not go well. - correct answer ✅"It sounds as if you have had another experience that did not go well." Rationale: The nurse's response validates Joan's feelings, which will encourage Joan to verbalize further. The nurse informs the client that she has developed constipation. The client tells the nurse that she hates hospitals because nobody ever tells you what's happening, and you end up with all these things going wrong.
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The client continues and states that she did everything her healthcare provider (HCP) told her to do. The client is convinced that the surgery must caused this and that they must have made a mistake in surgery. Which explanation by the nurse is accurate? -Refer the client to the surgeon to answer any questions about the surgical outcome. -Advise the client that an abdominal hysterectomy should not cause decreased peristalsis, so an error must have occurred during surgery. -Offer the client emotional support as she copes with this adverse outcome of surgery. -Explain to the client the multiple factors that can decrease peristalsis postoperatively, even when the desired surgical outcome is achieved. - correct answer ✅Explain to the client the multiple factors that can decrease peristalsis postoperatively, even when desired surgical outcome is achieved. Rationale: Constipation secondary to decreased peristalsis postoperatively is not considered a poor surgical outcome. Multiple factors surrounding abdominal surgery can lead to decreased peristalsis. Which postoperative medication is most likely to contribute to constipation? -Morphine sulfate, an opioid analgesic. -Ibuprofen, a non-opioid analgesic. -Promethazine, an antiemetic.
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Rationale: An adult needs 1,400 to 2,000 ml of fluid daily to prevent hardening of the stool. Pharmacological and Parenteral Therapies- The client's HCP has prescribed two medications for constipation: a one-time dose of bisacodyl suppositroy PR and docusate sodium 100 mg PO daily. The nurse explains that the bisacodyl suppository will have a laxative effect. Before administering the rectal suppository, how should the client be positioned? -High Fowler's. -Supine. -Prone. -Sim's. - correct answer ✅Sim's Rationale: The client should be in left side-lying Sim's position, with the knee flexed. When administering the rectal suppository, the nurse asks the client to take several slow, deep breaths. What is the rationale for this instruction? -Distract her from the suppository insertion. -Relax the anal sphincter and reduce discomfort. -Improve intestinal peristalsis and motility.
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-Reduce spasms from any hemorrhoids. - correct answer ✅Relax the anal sphincter and reduce discomfort Rationale: Deep breathing promotes relaxation of the anal sphincter, thereby reducing discomfort when the suppository is inserted. After administering the rectal suppository, how should the nurse document this action? -0900. Lubricant used when one bisacodyl suppository inserted. -0900. One suppository inserted because of constipation. -0900. One bisacodyl suppository administered per rectum for constipation, as prescribed. -0900. One bisacodyl administered for constipation. - correct answer ✅900. One bisacodyl suppository administered per rectum for constipation, as prescribed. Rationale: This documentation correctly identifies the medication, the dose, the time, and the route of administration, as well as the reason for administering the medication. Which statement provides the best documentation of the outcome from the suppository administration? -1100. Client reports that the suppository was not helpful in relieving constipation. -1100. Client reports producing six, 0.25 inch, hard pellets of brown stool following suppository administration.
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-Radiographic examination. Rationale: Digital rectal or a radiographic examination is the procedure performed to assess for the presence of a fecal impaction. The unlicensed assistive personnel (UAP) obtains sterile gloves and lubricant for the nurse and offers to perform the procedure since the nurse is busy. Which action is the most important for the nurse to implement? -Tell the UAP to perform the procedure using the lubricant, but advise her that the use of sterile gloves is not necessary. -Perform the procedure using the supplies obtained by the UAP. -Commend the UAP for her willingness to help and ask her to leave the supplies for the HCP, who must perform the procedure. -Ask the UAP to assist with client positioning while the nurse performs the procedure, while teaching the UAP about the correct supplies needed. - correct answer ✅Ask the UAP to assist with client positioning while the nurse performs the procedure, while teaching the UAP about the correct supplies needed. Rationale: The task should not be delegated to the UAP because it is an invasive procedure that places the client at risk. The UAP can be assigned to assist the nurse with client positioning. Assisting in this manner provides an opportunity for the nurse to teach the UAP that this is not a sterile procedure. The nurse should use
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nonsterile gloves, which are less costly than sterile gloves, and lubricant for this procedure. While performing the digital rectal exam, the nurse recognizes that the client may experience vagal nerve stimulation. This can result in which change in vital signs? -Increased blood pressure. -Increased temperature. -Decreased respirations. -Decreased pulse rate. - correct answer ✅Decreased pulse rate. Rationale: Vagal nerve stimulation can cause a reflex slowing of the heart rate. Management of Care The nurse notifies the HCP of the presence of a fecal impaction and receives a verbal prescription over the telephone for soap suds enema administration. When receiving the verbal prescription over the telephone, the nurse repeats the prescription back to the healthcare provider, who sounds angry and states, "Are you questioning my prescription?" How should the nurse respond to the healthcare provider?
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verbal prescriptions can be a source of error. The nurse should read back the complete prescription and have the verbal prescription signed within 24 hours. Some healthcare agencies do not allow verbal prescriptions, so it is important for the nurse to adhere to agency policy. The nurse administers the prescribed soap suds enema to illicit irritation to the colon to help with constipation. During the enema, Joan begins to experience abdominal cramping. What action(s) should the nurse take to relieve abdominal cramping? -Raise the head of the bed. -Slow the rate of the infusion. -Assess the client's vital signs. -Stop the enema and assist the client to the bathroom. -Roll the clamp to stop the enema until cramping subsides. - correct answer ✅-Slow the rate of the infusion. Rationale: Slowing the rate of the enema infusion and reassessing the client ,should reduce or stop the client's abdominal cramping. -Roll the clamp to stop the enema until cramping subsides. Rationale: This action will stop or slow down cramping. When cramping decreases, start enema again by slowly releasing the clamp to begin flow.
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Math The client informs the nurse she is interested in the amount of fluid administered via the enema but does not understand milliliters. The client received a total volume of 725 mL. How will the nurse accurately explain the amount of fluid to Joan using household measurements? -3 cups. -6 cups. -1 quart. -1/2 gallon. - correct answer ✅3 cups. Rationale: The conversion factors needed are: 30 ml = 1 ounce, and 1 cup = 8 ounces. 725 ml/30 = 24 ounces/8 = 3 cups. The nurse encourages the client to increase her daily oral fluid intake to 2 liters of fluid for the next few days. This is equivalent to how many 8-ounce cups of fluid daily? -Four -Six -Eight -Ten - correct answer ✅Eight to nine Rationale:
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-Orange juice and oatmeal with raisins. - correct answer ✅Orange juice and oatmeal with raisins. Whole-grain cereals and fruits are good sources of fiber, which is beneficial to bowel regularity.
