A nurse is caring for an older adult client who reports taking bisacodyl tablets daily. Which of the following responses should the nurse make?

"Irregular bowel movements are an indication of poor intestinal health."

"Decrease your intake of foods high in fiber."

"Excessive laxative use may cause an electrolyte imbalance."

"Chronic use of laxatives can lead to a tear in the rectal mucosa."

Answer and Explanation

The Correct Answer is C

Choice A reason:

This statement is not directly related to the client's use of bisacodyl tablets. It addresses irregular bowel movements in a general sense.

Choice B reason:

Decreasing fiber intake is not a recommended approach, especially for an older adult who may benefit from a balanced diet with adequate fiber.

Choice C reason:

This is the correct answer. Excessive use of laxatives, including bisacodyl, can lead to electrolyte imbalances. Bisacodyl is a stimulant laxative that can cause excessive fluid loss and potentially

disrupt electrolyte levels.

Choice D reason:

While chronic use of laxatives can lead to various complications, including potential harm to the rectal mucosa, this choice is not the most appropriate response to the client's current situation.

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Correct Answer is D

Explanation

Choice A reason:

Flushing the tube only when administering medications is not sufficient for proper maintenance. Regular flushing with water helps prevent clogs and ensures tube patency.

Choice B reason:

Cleaning the stoma with alcohol is not necessary and can be irritating to the skin. Mild soap and water are typically recommended for stoma care.

Choice C reason:

While being cautious to avoid dislodging the tube is important, it is not the primary indicator of correct tube management. Proper flushing and care are essential components of tube

maintenance.

Choice D reason:

Flushing the tube with water before and after each medication administration is a crucial step in maintaining tube patency and preventing clogs. This indicates that the patient is managing the

tube correctly.

A. Shiny, moist stoma B. Rosebud-like stoma orifice C. Purplish-colored stoma D. Stoma oozing red drainage

Correct Answer is C

Explanation

Choice A reason:

A shiny, moist stoma is generally a healthy sign, indicating good blood supply and adequate hydration of the stoma tissue. It is not a cause for concern.

Choice B reason:

A rosebud-like stoma orifice is a normal appearance for some types of stomas. It indicates a healthy stoma with good blood supply. This finding is expected and does not warrant concern.

Choice C reason:

A purplish-colored stoma may indicate compromised blood supply to the stoma, which is a serious concern and should be reported to the provider promptly. It may suggest inadequate blood flow to the stoma, which could lead to tissue necrosis.

Choice D reason:

Stoma oozing red drainage may be normal immediately postoperatively. It can be due to some oozing from the surgical site, and if it's minimal and stops after a short while, it's generally not a cause for concern.

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A nurse is caring for an older adult client who reports taking bisacodyl tablets daily. Which of the following responses should the nurse make?

Nursing Test Bank

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