Constipation

Which type of diet should the nurse recommend?

High fiber.

Which is the most important action for the nurse to perform when assessing bowel sounds?

- Listen for up to 5 minutes when auscultating for bowel sounds. - Begin auscultation in the right lower quadrant.

To determine the presence of a fecal impaction, the nurse prepares Janelle for which prescribed procedure?

- Radiographic examination. - Digital rectal examination.

Which statement provides the best documentation describing the outcome from the suppository administration?

1100. Client produced six, ¼ inch, hard pellets of brown stool following suppository administration.

Which response by the nurse accurately describes a barium swallow?

A barium liquid is swallowed and a series of x-rays are taken.

What action should the nurse implement?

Administer the enema as prescribed and obtain the HCP's signature the next day.

What task can the nurse delegate to the UAP?

Assist the client with a bed bath and hygiene if required. Assist the client who vomited with mouth care after the RN administers an antiemetic.

The nurse administers the first dose of docusate sodium. This medication primarily alters which aspect of a client's bowel movement?

Consistency.

Which nursing diagnosis should the nurse include in Janelle's plan of care?

Constipation related to surgery and anesthesia.

Before administering the rectal suppository, how should the client be positioned?

Sim's.

What actions should the nurse take to relieve the abdominal cramping?

Slow the rate of the infusion. Roll the clamp to stop the enema until cramping subsides.

What other questions should the nurse ask Janelle?

"How often do you get out of bed and walk?"

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?

"I want to ensure that I transcribe this prescription correctly to avoid error."

Which response by the nurse will encourage continued verbalization by the client?

"It sounds as if you have had another experience that did not go well."

How will the nurse explain to Janelle the action of the laxative?

"Soften the stool, distend the rectum to expel the stool."

How should the nurse respond?

"Tell me what is making you feel so upset."

After administering the rectal suppository, it is most important for the nurse to document which information?

0900. One bisacodyl suppository administered per rectum for constipation, as prescribed.

How will the nurse accurately explain the amount of fluid to Janelle using household measurements?

3 cups

The 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?

Ask the UAP to assist with client positioning while the nurse performs the procedure, while teaching the UAP about the correct supplies needed.

Which assessment is most important for the nurse to perform?

Auscultate bowel sounds.

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?

Decreased pulse rate.

The nurse encourages Janelle to increase her daily oral fluid intake to 2 liters of fluid for the next few days. The nurse advises Janelle to drink a minimum of how many 8-ounce cups of fluid daily?

Eight to nine.

Janelle responds, "I did everything my HCP told me to do. The surgery must have caused this. They must have made a mistake." Which explanation by the nurse is accurate?

Explain to the client the multiple factors that can decrease peristalsis postoperatively, even when the desired surgical outcome is achieved.

The nurse auscultates for Janelle's bowel sounds and hears faint gurgling sounds after 3 minutes. Which assessment finding should the nurse document?

Hypoactive bowel sounds.

Which sequence should the nurse perform the abdominal assessment?

Inspection, auscultation, percussion, palpation.

Which postoperative medication is most likely to contribute to constipation?

Morphine sulfate, an opioid analgesic.

The nurse uses the hospital breakfast menu as a teaching tool. Which breakfast selection by Janelle indicates that she understands teaching about dietary measures to promote bowel regularity?

Orange juice and oatmeal with raisins.

When administering the rectal suppository, the nurse asks Janelle to take several slow, deep breaths. What is the rationale for this instruction?

Relax the anal sphincter and reduce discomfort.

What impact does this fluid intake have on Janelle's bowel patterns?

This inadequate fluid intake has contributed to her constipation.