Which laxative would be contraindicated for this patient? d. softens and facilitates the removal of intestinal polyps, The student nurse is preparing a presentation on how to perform a physical assessment on the abdomen. c. Transporting the specimen Constipation 2. c. Begin by measuring from the tip of the client's nose to the earlobe to the xiphoid process. Client report of nausea B. A nurse is providing preoperative teaching for a client who is scheduled for a gastrectomy. B. Appendicitis Which of the following statements should the nurse include in the teaching? b. cabbage Green (d) The stationary object is 106 times the mass of the moving object. a. Monitor urine pH. C. Brain trauma Which is an effect of prolonged use of mineral oil to relieve constipation? b. Diarrhea Statistics and Incidences. A nurse is caring for an older adult who has constipation. Remove the tubing immediately and discontinue the procedure. What result would contraindicate the safe administration of an enema? Client/Family Teaching Nursing care plans For Constipation. a. Gently work the finger around and into the hardened mass to break it up and then remove pieces of it. The incontinence pattern A nurse is teaching an older adult client who reports constipation. A nurse is administering a large-volume cleansing enema to a patient prior to surgery. A. a. Decrease expected blood loss during surgery a. 1 d. "Only if the stool has not been contaminated by urine. B. If the specimen contains barium or enema solution, document this on the container. Which of the following instructions should the nurse include in the teaching? Chronic Constipation Clients should be taught that repeatedly ignoring the sensation of needing to defecate could result in which of the following? Which statement by a participant suggests a need for further education? b. mineral oil D. Depression The provider prescribes warfarin PO without discontinuing the heparin. e. administration of enemas until clear, A physician orders an enema to effect rapid colonic emptying in a client who is experiencing severe abdominal cramping due to constipation. Which assessment question will the nurse ask? d. Plans to eat a snack of fruit twice per day. c. using a warm bedpan when Ms. Young feels the urge to void a. Fecal impaction Ignoring the urge to defecate. a. 4. a. Instill digestive enzymes, as ordered. Which of the following action should the nurse take? Soapsuds enemas act by stimulating peristalsis through intestinal irritation. c. increases the volume of the stool, making defecation easier Which of the following instructions should the nurse include in the teaching? Which of the following is the appropriate intervention? b. Nasogastric tubes should not be irrigated. The nurse explains that the client will wear antiembolism stockings during and after the procedure. b. a. onions A. b. A risk that the peristomal skin will become excoriated Which of the following actions should the nurse take to alleviate the clients concern? Which of the following strategy should she include illustrate the concept of joint protection? (B) hazy D. Report burning with urination to the provider. The client traveled to South America two weeks ago. Tap water What are some foods that could cause blockage in a colostomy? E. Hold the enema solution 12 inches above the anus. Season foods with herbs and spices. What solution best meets this client's needs? During the procedure the patient tells the nurse she is feeling dizzy and nauseated, and then vomits. It drains the bladder. A nurse is reviewing the laboratory results for a client who has a history of atherosclerosis and notes elevated cholesterol levels. A bulk-forming laxative d. Inform client that a chalky-tasting barium contrast mixture will be given to drink before the test. What is the appropriate nursing intervention for this client? 3. urinary elimination 1. skin integrity In the hospital, a clean technique is used for catheter insertion B. d. soap and water, What is the most common type of colostomy that needs to be irrigated to help promote regular evacuation of feces? d. 1 in (2.5 cm). d. discontinuation of the amoxicillin and the administration of a different antibiotic, A hypertonic enema solution lubricates the stool and intestinal mucosa, making stool passage more comfortable. Digital removal of stool may cause parasympathetic stimulation. c. "I will have a fecal occult blood test done every 5 years." The nurse should anticipate a prescription for which of the following medications? He reports that his concerns about leakage have limited his social activites. A nurse is assessing the abdomen of a patient who is experiencing frequent bouts of diarrhea. ", A nurse is caring for a child who is in the postoperative period following a tonsillectomy. Connect all catheters and drains to a single collection device. Which of the following is most likely to validate that a client is experiencing intestinal bleeding? d. A stool softener, Which symptom is a known side effect of antibiotics? d. yellow Lower the solution after instilling about 150 mL of solution. ", A. What nursing interventions should be applied to all 3? D. Apply barrier cream, A. When was your last bowel movement? Alcohol and coffee tend to have a constipating effect on clients. A. Select all that apply. B. 3. urinary elimination C. This position allows the solution to flow downward by gravity along the curve of the sigmoid colon and rectum, thus improving the effectiveness of the enema. B. B. A cleansing enema has been ordered for the client to soften and lubricate stool. a. What should be the nurse's next action? For which adverse effect would the nurse monitor in this patient? Bear down hard when defecating Place the enema 12-18 inches above the anus d. age of the patient, Mr. Bales is 60 year old and alert. "I eat two eggs for breakfast each morning. When the procedure is finished, the nurse notes that the stoma is protruding into the bag. A communicating wall remains between the proximal and the distal bowel. What should the nurse recommend that the patient eat to best increase the bulk and fecal material? A. Constipation d. Collecting the specimen E. Lean turkey, A. Kidney beans C. Frequent swallowing and clearing of the throat e. "The client makes neutral or positive statements about the ostomy. 3 Auscultation a. Oil-retention C. Administer the enema while the patient sits on the toilet. The nurse observes the unlicensed assistive personnel (UAP) serving a food tray to a client with diarrhea. D. 3, A patient is experiencing constipation. A nurse is replacing the ostomy appliance for a patient whose newly created colostomy is functioning. A patient has a fecal impaction. (Select all that apply.) What are the contraindications for enemas? C. Snoring sounds when inhaling 30MJkg1, .) "This test detects heme, a type of iron compound in blood in the stool." Which action is an appropriate step in this procedure? a. Lettuce Select all that apply. "This happens when you bear down causing an increase in blood volume to the heart and resulting in your heart rate becoming too rapid." c. Fish and dried lentils Excessive laxative use B. a. Position the bed flat and assist the client onto his or her left side. At least 30 mins, or as long as they can hold it. E. Increase fluid intake to 3 L/day. a. A nurse is reinforcing teaching with a client that reports having constipation. d. Mrs. Lonte reports fullness and diarrhea after breakfast. Dry, hard stool c. Clamp the tube for a brief period and resume at a slower rate. \end{array} Which of the following findings are indicative of this condition? B. a. Hypertonic Select all that apply. B. Squatting c. removing the tubing immediately a. Prone Patients typically experience other symptoms such as hard stools,. a. (a) the smallest atom in group 13; A coal power plant with 30% efficiency burns 10 million kilograms of coal a day. c. Carminative c. prune juice with breakfast Which recommended patient teaching points would the nurse stress? Select all that apply. A. c. Disconnect the nasogastric tube from the suction for 1 hour prior to the assessment of bowel sounds. D. Pull the curtain around the patient's bed and drape the patient. A. Stimulation of the vagus nerve The nurse needs to collect a stool specimen for culture from a client. a. administration of an antidiarrheal drug and continuance of the amoxicillin d. Stroking Ms. youngs leg or thigh, b. 2. A. A nurse is talking w/a client who reports constipation. A nurse needs to administer a hypertonic enema solution to the client. b. pulling curtains around him to provide privacy during voiding D. "Carbonated beverages can help control odor. The provider has prescribed an enema. A nurse is caring for a client who practices Orthodox Judaism. Reduce sodium intake. A nurse is teaching a patient with a new ileostomy about incorporating preventive strategies at home. What are some assessment questions that could be asked? The nursing student is performing a focused gastrointestinal assessment. As a nurse prepares to assist Mrs. P with her newly created ileostomy, she is aware of which of the following? Adds water to the bowel Which color stool does the nurse identify as abnormal? c. "Auscultated abdomen for bowel sounds. d. "There may be an issue with your colon that is causing these type of symptoms. b. Assessing a client's GI system Having Ms. young ignore the urge to void until her bladder is full E. Increased activity, A. What is the next step for the nurse? b. Which examples correctly describe these effects? e. Platelet count of 19,500/mm3 (195.00 109/L) A Alcohol Diarrhea commonly occurs with amoxicillin clavulanate use, If a patient was instructed to avoid foods that may have a laxative effect, the nurse would advise the patient to avoid which of the following foods? D. Regular use of glycerine suppositories, C. Increase cellulose and fluid in the diet. d. A patient with Crohn's disease. d. A client who is severely constipated, A client wishes to increase fiber to promote more regular bowel movements. A student nurse is preparing to administer a client's ordered large-volume enema. Which of the following information should the nurse include in the teaching? Which of the following actions should the nurse take first? C. Use water-soluble jelly for lubrication. b. As long as pure _________ soap is used, it is considered a safe procedure. a. d. "The client agrees to take prescribed antidepressants." A. E. Encourage the patient to rock back and forth while defecating, A. Which of the following foods should the nurse instruct the client to avoid? D. Reddened areas over bony prominences, B. a. B. C. Constipation d. Monitoring bowel movements, A nurse is caring for a patient who is post-surgical following an IPAA.
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