Constipation

Which assessment is most important for the nurse to perform? - Auscultate bowel sounds. - Measure abdominal girth. - Observe incisional staples. - Measure blood pressure.

- Auscultate bowel sounds. (The subjective data reported by Janelle (bloated and nauseated) and objective data gathered by the nurse (abdomen firm and distended) suggest that Janelle may have decreased peristalsis. This can be assessed by auscultation of the bowel sounds.)

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? - Four to five. - Six to seven. - Eight to nine. - Ten to twelve.

- Eight to nine. (One 8-ounce cup contains 240 mL (8 x 30 mL/ounce) Two liters = 2,000 mL 2,000 mL/240 mL = 8.33 cups/day.)

Janelle has moderate results from the enema and tolerates the procedure well but states she feels a second enema would be beneficial. While talking with Janelle, the nurse receives report from the UAP that another client is vomiting. The nurse tells Janelle she will return as soon as she deals with the other client's problem.

...

The nurse observes that Janelle's abdomen is firm and distended. The nurse performs an abdominal assessment.

...

While the nurse is completing the assessment, Janelle begins to cry and laments, "I just knew something would go wrong."

...

What other questions should the nurse ask Janelle? - "How often do you get out of bed and walk?" - "Are you using your incentive spirometer regularly?" - "When was your abdominal dressing last changed?" - "Are you wearing your compression devices while in bed?"

- "How often do you get out of bed and walk?" (Immobility is a major risk factor for constipation.)

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."

- "It sounds as if you have had another experience that did not go well." (The nurse's response validates Janelle's feelings, which will encourage Janelle to verbalize further.)

How will the nurse accurately explain the amount of fluid to Janelle using household measurements? - 3 cups. - 6 cups. - 1 quart. - 1/2 gallon.

- 3 cups. (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 auscultates for Janelle's bowel sounds and hears faint gurgling sounds after 3 minutes. Which assessment finding should the nurse document? - Hypoactive bowel sounds. - Normal bowel sounds. - Paralytic ileus. - Reduced peristalsis.

- 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.)

Which postoperative medication is most likely to contribute to constipation? - Morphine sulfate, an opioid analgesic. - Ibuprofen, a non-opioid analgesic. - Promethazine, an antiemetic. - Cefazolin, an antibiotic.

- Morphine sulfate, an opioid analgesic. (The most common adverse effect of opioid analgesics is constipation.)

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? - Skim milk and toasted bagel with jam. - Coffee and pancakes with maple syrup. - Herbal tea and bacon and eggs. - Orange juice and oatmeal with raisins.

- Orange juice and oatmeal with raisins. (Whole grain cereals and fruits are good sources of fiber, which is beneficial to bowel regularity.)

Before administering the rectal suppository, how should the client be positioned? - High Fowler's. - Supine. - Prone. - Sim's.

- Sim's. (The client should be in Sim's position, on the left side, with the knee flexed.)

Further assessments and testing are ordered to assist in the diagnosis of constipation. An upper GI series (Barium swallow) is ordered. Janelle appears nervous, and asks the nurse to explain this procedure.

...

Janelle expresses her thanks to the nurse and states that she feels confident in her ability to manage her diet, fluid intake, and activity to ensure regular bowel patterns when she is discharged.

...

Janelle tells the nurse, "I hate hospitals because nobody ever tells you what's happening, and you end up with all these things going wrong."

...

The next day, Janelle has still not expelled additional feces.

...

The nurse administers the prescribed soap suds enema to illicit irritation to the colon to help with constipation. During the enema, Janelle begins to experience abdominal cramping.

...

The nurse assesses the client who is vomiting and acts to alleviate this problem. The nurse returns to Janelle's room. Janelle is interested in the amount of fluid administered via the enema but does not understand milliliters. Janelle received a total volume of 725 mL.

...

The nurse explains to Janelle that she has developed constipation, probably as the result of a number of factors. Janelle has not been taking oral fluids well, but she has been receiving IV fluids. Her total fluid intake for the previous 24 hours was 1,000 mL. The nurse explains risk factors that can contribute to constipation.

...

The nurse notifies the HCP of the presence of a fecal impaction and receives a verbal prescription over the telephone for 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? - "Make sure you sign this verbal prescription within 24 hours." - "I want to ensure that I transcribe this prescription correctly to avoid error." - "You should be glad I want to ensure the accuracy of this prescription." - "I have the responsibility to question any prescriptions I do not feel are correct."

- "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.)

How will the nurse explain to Janelle the action of the laxative? - "The stool will be broken up so that it will be small enough to be expelled from your rectum." - "Soften the stool, distend the rectum to expel the stool." - "Increases the fluid volume in the colon, stimulating evacuation of stool." - "You may experience abdominal cramping and may even have some diarrhea as the result of this medication."

- "Soften the stool, distend the rectum to expel the stool." (Laxatives soften the stool and stimulate the rectal mucosa to produce soft or liquid stool.)

How should the nurse respond? - "This is a minor problem. We'll have you better very soon." - "You have to expect that problems will occur after surgery." - "Tell me what is making you feel so upset." - "Why are you letting this upset you?"

- "Tell me what is making you feel so upset." (This open-ended statement encourages the client to express further concerns and fears.)

After administering the rectal suppository, it is most important for the nurse to document which information? - 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 laxative (bisacodyl) administered for constipation.

- 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? - 1100. Client reports that the suppository was not helpful in relieving constipation. - 1100. Client produced six, ¼ inch, hard pellets of brown stool following suppository administration. - 1100. Client will need additional treatment to resolve problem of constipation. - 1100. Suppository administration produced only a small amount of feces.

- 1100. Client produced six, ¼ inch, hard pellets of brown stool following suppository administration. (This documentation provides the most specific objective data related to the effectiveness of the suppository.)

Which response by the nurse accurately describes a barium swallow? - Barium is inserted into the rectum and a series of x-rays are taken. - A barium liquid is swallowed and a series of x-rays are taken. - A scope is inserted into the mouth, down the throat, and into the stomach. - A flexible scope is inserted into the anus that visualizes the rectum and colon.

- A barium liquid is swallowed and a series of x-rays are taken. (An upper GI series involves swallowing a barium liquid, followed by a series of x-rays taken of the esophagus, stomach and duodenum.)

What action should the nurse implement? - Wait to administer the enema until the HCP is able to sign the prescription in person. - Administer the enema as prescribed and obtain the HCP's signature the next day. - Explain to the HCP that verbal prescriptions are not legally defensible, and a written prescription is needed. - Ask the charge nurse to assist with preparing a variance report to explain the use of a verbal prescription.

- 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.)

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? - 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.

- Ask the UAP to assist with client positioning while the nurse performs the procedure, while teaching the UAP about the correct supplies needed. (This task should not be delegated to the UAP because it is an invasive procedure that places a client at risk. The UAP can be assigned to assist the nurse with client positioning. Having the UAP assist in this manner provides an opportunity for the nurse to teach the UAP that this is not a sterile procedure. The nurse should use nonsterile exam gloves, which are less costly than sterile gloves, and lubricant for this procedure.)

The remainder of Janelle's surgical recovery is uneventful. She continues to drink plenty of fluids, increases her activity, and has regular bowel movements. Janelle eats a regular diet with no restrictions and asks the nurse about foods that promote bowel regularity.

...

What task can the nurse delegate to the UAP? Select all that apply - Determine whether Janelle needs another enema. - Give the vomiting client an antiemetic. - Teach Janelle how to self-administer the enema. - 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.

- Assist the client with a bed bath and hygiene if required. (Hygiene and comfort care are both within the UAP's scope of practice.) - Assist the client who vomited with mouth care after the RN administers an antiemetic. (Hygiene and comfort care are both within the UAP's scope of practice.)

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

- Consistency. (Docusate sodium is a stool softener. The desired effect is to soften hard stool (alter the consistency) for ease of elimination.)

Which nursing diagnosis should the nurse include in Janelle's plan of care? - Risk for constipation and lack of fluid intake. - Inadequate fluid intake, resulting in constipation. - Constipation related to surgery and anesthesia. - Constipation as manifested by decreased bowel sounds.

- Constipation related to surgery and anesthesia. (This diagnostic statement uses the correct format and identifies both the problem and the etiology.)

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

- Decreased pulse rate (Vagal nerve stimulation can cause a reflux slowing of the heart rate).

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? - 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.

- Explain to the client the multiple factors that can decrease peristalsis postoperatively, even when the desired surgical outcome is achieved. (Constipation secondary to decreased peristalsis postoperatively is not considered a poor surgical outcome. Multiple factors surrounding abdominal surgery can lead to decreased peristalsis.)

Which type of diet should the nurse recommend? - High fiber. - Low sodium. - Low carbohydrates. - High protein.

- High fiber (High fiber foods accelerate the passage of food through the intestines, which is important for bowel regularity.)

Which sequence should the nurse perform the abdominal assessment? - Auscultation, inspection, percussion, palpation. - Inspection, palpation, auscultation, percussion. - Inspection, auscultation, percussion, palpation. - Auscultation, percussion, inspection, palpation.

- Inspection, auscultation, percussion, palpation. (Percussion and palpation can alter abdominal findings, so inspection and auscultation are indicated prior to percussion and palpation.)

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.

- 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.)

To determine the presence of a fecal impaction, the nurse prepares Janelle for which prescribed procedure? Select all that apply - Insertion of a rectal tube. - Enema administration. - Radiographic examination. - Digital rectal examination. - Sigmoidoscopy.

- Radiographic examination. Digital rectal or a radiographic examination is the procedure performed to assess for the presence of a fecal impaction. - Digital rectal examination. (Digital rectal examination is the procedure performed to assess for the presence of a fecal impaction.)

When administering the rectal suppository, the nurse asks Janelle to take several slow, deep breaths. What is the rationale for this instruction? - Distract Janelle from the suppository insertion. - Relax the anal sphincter and reduce discomfort. - Improve intestinal peristalsis and motility. - Reduce spasms from any hemorrhoids.

- Relax the anal sphincter and reduce discomfort. (Deep breathing promotes relaxation of the anal sphincter, thereby reducing discomfort when the suppository is inserted.)

What actions should the nurse take to relieve the abdominal cramping? Select all that apply - Raise the head of the bed - Slow the rate of the infusion - Assess the client's vital signs - Stop the enema and assist Janelle to the bathroom - Roll the clamp to stop the enema until cramping subsides

- 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 enema until crampting subsides (This action will stop or slow down crampting. When crampting decreases, start enema again by slowly releasing the clamp to begin flow.)

What impact does this fluid intake have on Janelle's bowel patterns? - This inadequate fluid intake has contributed to her constipation. - This sufficient amount of fluid intake has not affected her bowel patterns. - This large amount of fluid intake has helped keep her feces soft. - Intravenous fluids have little or no impact on intestinal contents and bowel patterns.

- 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.)

The nurse determines that Janelle's inadequate fluid intake, decreased mobility, and opioid use are significant factors in the development of her constipation.

...

The nurse explains to Janelle that her HCP has prescribed two medications: a one-time dose of bisacodyl rectal suppository and docusate sodium 100 mg PO daily. The nurse explains that the bisacodyl suppository will have a laxative effect.

...