C/S: Constipation

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

a. 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.

Which action is most important for the nurse to perform? a. Auscultate bowel sounds. b. Measure abdominal girth. c. Observe incisional staples. d. Measure blood pressure.

a. 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.

The nurse instructs the client on which activity that would minimize risk for constipation? Getting out of bed and ambulating. Regular use of the incentive spirometer. The need for frequent abdominal dressing changes. The importance of wearing compression devices while in bed.

a. Getting out of bed and ambulating. Immobility is a major risk factor for constipation.

The nurse auscultates for the client's bowel sounds and hears faint gurgling after 3 minutes. Which assessment finding should the nurse document? a. Hypoactive bowel sounds. b. Normal bowel sounds. c. Paralytic ileus. d. Reduced peristalsis.

a. 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.

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

What impact does insufficient fluid intake have on the client'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.

a. This inadequate fluid intake has contributed to her constipation. An adult needs 1,500 to 2,000 mL of fluid daily to prevent hardening of the stool.

Which type of foods should the nurse recommend? With fiber. With Low sodium. Low in carbohydrates. With high protein.

a. With fiber Foods with fiber accelerate the passage of food through the intestines, which is important for bowel regularity.

What actions should the nurse take to relieve the abdominal cramping? (Select all that apply.) 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 the client to the bathroom. Roll the clamp to stop the enema until cramping subsides

b. & e. 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.

Which is the most important action for the nurse to perform when assessing bowel sounds? (Select all that apply.) Select all that apply a. Ask the client if she has lost or gained any weight. b. Listen for up to 5 minutes when auscultating for bowel sounds. c. Perform a rectal exam. d. Inspect the client's abdomen while she is in a semi-Fowler's position. e. Begin auscultation in the right lower quadrant.

b. & e. 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. 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.

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 reports producing six, 0.25 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.

b. 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.

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.

b. 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.

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.

b. 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.

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

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

To determine the presence of a fecal impaction, the nurse would prepare the client for which probable prescribed procedure(s)? (Select all that apply.) Select all that apply Insertion of a rectal tube. Enema administration. Radiographic examination. Digital rectal examination. Sigmoidoscopy.

c. & d. Digital rectal or a radiographic examination is the procedure performed to assess for the presence of a fecal impaction.

After administering the rectal suppository, how should the nurse document this action? 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 bisacodyl administered for constipation.

c. 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.

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? Four Six Eight Ten

c. Eight 1 ounce = 30mL One 8-ounce cup contains - 8 x 30mL = 240mL Two liters = 2,000 mL 2,000 mL/240 mL = 8.33 cups/day.

In which sequence should the nurse perform the abdominal assessment? a. Auscultation, inspection, percussion, palpation. b. Inspection, palpation, auscultation, percussion. c. Inspection, auscultation, percussion, palpation. d. Auscultation, percussion, inspection, palpation.

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

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

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

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? 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.

d. 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.

While performing the digital rectal exam, the nurse understands 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.

d. Decreased pulse rate. Vagal nerve stimulation can cause a reflex slowing of the heart rate.

The client continues and states that she did everything her healthcare provider (HCP) told her to do. The client is conveinced that the surgery must caused this and that they must have made a mistake in surgery. Which explanation by the nurse is accurate? a. Refer the client to the surgeon to answer any questions about the surgical outcome. b. Advise the client that an abdominal hysterectomy should not cause decreased peristalsis, so an error must have occurred during surgery. c. Offer the client emotional support as she copes with this adverse outcome of surgery. d. Explain to the client the multiple factors that can decrease peristalsis postoperatively, even when the desired surgical outcome is achieved.

d. 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 response by the nurse will encourage continued verbalization by the client? a. All of the nurses are very busy here, and they are doing the best job they can. b. You should write down your questions so you can get some answers. c. I will be happy to tell you everything that's happening, so nothing else will go wrong. d. It sounds as if you have had another experience that did not go well.

d. It sounds as if you have had another experience that did not go well. The nurse's response validates the client's feelings, which will encourage her to verbalize further.

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? 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. Submit Previous Section

d. 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.

d. Sim's. The client should be in left side-lying Sim's position, with the knee flexed.