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The nurse observes the client's abdomen is firm and distended. The nurse performs an abdominal assessment. In which sequence should the nurse perform the abdominal assessment? - correct answer ✅1) Inspection 2) auscultation 3) percussion, 4) palpation. Rationale: Percussion and palpation can alter abdominal findings, so inspection and auscultation are indicated prior to percussion and palpation. Which action is most important for the nurse to perform? - correct answer ✅Auscultate bowel sounds. Rationale: 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? - correct answer ✅- Listen for up to 5 minutes when auscultating for bowel sounds. -Begin auscultation in the right lower quadrant. 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.
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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. The nurse auscultates for the client's bowel sounds and hears faint gurgling after 3 minutes. Which assessment finding should the nurse document? - correct answer ✅Hypoactive bowel sounds. Psychosocial Integrity - While the nurse is interviewing the client, she begins to cry and moan, and states she just knew something would go wrong. How should the nurse respond? - correct answer ✅Tell me what is making you feel so upset. 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?
- correct answer ✅It sounds as if you have had another experience that did not go well. Rationale: The nurse's response validates the client's feelings, which will encourage her 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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Rationale: An adult needs 1,500 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?
- 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? - 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? - correct answer ✅0900. One Bisacodyl suppository administered per rectum for constipation, as prescribed.
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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 describing the outcome from the suppository administration? - correct answer ✅1100. Client reports producing six, 0.25 inch, hard pellets of brown stool following suppository administration. Rationale: This documentation provides the most specific objective data related to the effectiveness of the suppository. The next day, the client still has not expelled additional feces. To determine the presence of a fecal impaction, the nurse would prepare the client for which probable prescribed procedure(s)? - correct answer ✅- Radiographic examination.
- Digital rectal examination. Rationale: Digital rectal or a radiographic examination is the procedure performed to assess for the presence of a fecal impaction. Rationale: Digital rectal 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? - correct answer ✅Ask
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What action should the nurse implement? - correct answer ✅Administer the enema as prescribed and obtain the HCP's signature the next day. Rationale: A verbal prescription is legally permissible. The nurse should, however, take measures to ensure client safety because 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, the client begins to experience abdominal cramping. What actions should the nurse take to relieve the abdominal cramping? - correct answer ✅- Slow the rate of the infusion.
- Roll the clamp to stop the enema until cramping subsides. Rationale: Slowing the rate of the enema infusion and reassessing the client ,should reduce or stop the client's abdominal cramping. 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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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 using household measurements? - correct answer ✅3 cups. Rationale: The conversion factors needed are as follows: 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? - correct answer ✅Eight Rationale: 1 ounce = 30mLOne 8-ounce cup contains - 8 x 30mL = 240mLTwo liters = 2,000 mL2,000 mL/240 mL = 8.33 cups/day. The remainder of the client's surgical recovery is uneventful. She continues to drink plenty of fluids, increases her activity, and has regular bowel movements. She eats a regular diet with no restrictions and asks the nurse about foods that promote bowel regularity. Which type of foods should the nurse recommend? - correct answer ✅With fiber. Rationale: Foods with fiber accelerate the passage of food through the intestines, which is important for bowel regularity.
