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Meet the Client - correct answer ✅A client on the medical surgical unit had an abdominal hysterectomy three days ago and is now reporting abdominal bloating, pain, and nausea. She is reluctant to eat or drink anything stating, "The smell of food makes me nauseated." She informs the nurse that she feels constipated and has not passed a bowel movement since prior to surgery. Health Promotion and Maintenance - correct answer ✅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 ✅Inspection, auscultation, percussion, palpation.
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? - correct answer ✅Auscultate bowel sounds.
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.) - correct answer ✅Listen for up to 5 minutes when auscultating for bowel sounds. (The nurse must listen for up to 5 minutes before determining what type of bowel sounds are present.)
Begin auscultation in the right lower quadrant. (The nurse should auscultate in the right lower quadrant, and then proceed to the other quadrants.) 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.
Normally, bowel sounds are heard 5 to 35 times per minute. When bowel sounds are heard only after listening for 3 minutes, they are recorded as hypoactive. Psychosocial Integrity - correct answer ✅While the nurse is completing the assessment, the client begins to cry and moan, "I just knew something would go wrong." How should the nurse respond? - correct answer ✅"Tell me what is making you feel so upset."
This open-ended statement encourages the client to express further concerns and fears.
The nurse instructs the client on which activity that would minimize risk for constipation? - correct answer ✅Getting out of bed and ambulating
Immobility is a major risk factor for constipation. What impact does insufficient fluid intake have on the client's bowel patterns? - correct answer ✅This inadequate fluid intake has contributed to her constipation.
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. - correct answer ✅- Before administering the rectal suppository, how should the client be positioned? - correct answer ✅Sim's
The client should be in Sim's position, on the left side, 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.
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.
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.
This documentation provides the most specific objective data related to the effectiveness of the suppository. Reduction of Risk Potential - correct answer ✅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)?
Vagal nerve stimulation can cause a reflex slowing of the heart rate. Management of Care - correct answer ✅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 HCP, who sounds angry and shouts, "Are you questioning my prescription?" Which approach by the nurse is the best response to the angry HCP? - correct answer ✅"I want to ensure that I transcribe this prescription correctly to avoid error."
This assertive response teaches the HCP the purpose of repeating back verbal prescriptions. What action should the nurse implement? - correct answer ✅Administer the enema as prescribed and obtain the HCP's signature the next day.
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.
Reduction of Risk Potential - correct answer ✅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? (Select all that apply.) - correct answer ✅Slow the rate of the infusion. (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. (This action will stop or slow down cramping. When cramping decreases, start enema again by slowly releasing the clamp to begin flow.) The client has moderate results from the enema and tolerates the procedure well but states she feels a second enema would be beneficial. While talking with her, the nurse receives a report from the unlicensed assistive personnel (UAP) that another client is vomiting. The nurse tells this client she will return as soon as she deals with the other client's problem. Previous Section - correct answer ✅- 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. - correct answer ✅3 cups
Foods with fiber accelerate the passage of food through the intestines, which is important for bowel regularity. The nurse uses the hospital breakfast menu as a teaching tool. Which breakfast selection by the client indicates that she understands teaching about dietary measures to promote bowel regularity? - correct answer ✅Orange juice and oatmeal with raisins.
Whole grain cereals and fruits are good sources of fiber, which is beneficial to bowel regularity.
