A nurse is caring for several clients who are at risk of developing a pressure injury. Which of the following clients is most at risk?

Choice A rationale:

Taking colesevelam on an empty stomach is not necessary. This medication can be taken with food to reduce gastrointestinal side effects.

Choice B rationale:

Increasing fiber in the diet is generally beneficial for bowel health, but it is not specific to the use of colesevelam powder for oral suspension.

Choice C rationale:

This is the correct answer because if the oral suspension of colesevelam is cloudy after mixing, it indicates that the medication may have degraded or is not suitable for consumption. Discarding the cloudy suspension ensures that the client receives the appropriate dose and effectiveness of the medication.

Choice D rationale:

Avoiding grapefruit juice is important for some medications, but it is not relevant to colesevelam. Grapefruit juice can interfere with the metabolism of certain drugs, but it does not have a significant effect on colesevelam.

Choice A rationale:

Increased peristalsis would be a positive sign and not indicative of postoperative paralytic ileus. Increased peristalsis would mean the bowel is functioning well.

Choice B rationale:

Abdominal distension is a classic sign of postoperative paralytic ileus, where the bowel's motility is reduced or absent. This condition can lead to a buildup of gas and fluids, causing the abdomen to become distended.

Choice C rationale:

Proximal high-pitched bowel sounds can be a normal finding after surgery, but they are not indicative of paralytic ileus. They may even be heard as the bowel recovers its motility.

Choice D rationale:

Passing flatus is a positive sign, as it indicates that the bowel is working and the patient is passing gas. This is not indicative of a postoperative paralytic ileus, which is characterized by the absence of bowel movement.