HESI Fundamental

A client with multiple sclerosis is at risk for constipation. A home care nurse teaches the client to do which of the following to manage this problem in the home setting?

"Initiate a bowel movement (BM) every other day, 45 minutes after the largest meal of the day"

A client who is advised to take senna (Senokot) for the treatment of constipation asks the nurse how this medication works. The nurse responds knowing that it:

Accumulates water in the stool and increases peristalsis

A nurse is caring for a child who has wrist restraints in place after a tonsillectomy. The nurse prepares a plan of care and determines that which of the following nursing interventions would receive highest priority regarding the restraints?

Assessing color, sensation, and pulses distal to the restraint

A nurse is providing instructions to the nursing assistant who will be caring for a client who has hand restraints. The nurse instructs the nursing assistant to check the client's skin and circulation under the restraints:

Every 30 min

"A client has an order for "enemas until clear" before major bowel surgery. After preparing the equipment and solution, the nurse assists the client into which of the following positions to administer the enema?"

Left-lateral Sims' position

An older client has been using cascara sagrada on a long-term basis to treat constipation. The nurse determines that which laboratory result is a result of the side effects of this medication?

Potassium 3.1 mEq/L

A nurse is caring for a 9-month-old child following cleft palate repair who has elbow restraints applied. The mother visits the child and asks the nurse to remove the restraints. The nurse takes which appropriate action?

Removes a restraint from one extremity

"A physician has written an order for a vest restraint to be applied on a client from 10:00 p.m. to 7:00 a.m. because the client becomes disoriented during the night and is at risk for falls. At 11:00 p.m., the charge nurse makes rounds on all of the clients in the unit. When assessing the client with the vest restraint, which observation by the charge nurse would indicate that the nurse who cared for this client performed an unsafe action in the use of the restraint?"

The restraint was applied tightly