A nurse is contributing to the plan of care for a client who is starting bowel training for the management of fecal incontinence. Which of the following interventions should the nurse recommend?
Limit the client's physical activity until bowel continence is achieved.
Limit the client's fluid intake to 1500 mL/day.
Instruct the client to limit their intake of high-fiber foods.
Assist the client to the restroom 30 minutes after meals.
The Correct Answer is D
Choice A Reason:
Limiting the client's physical activity is not generally recommended as part of bowel training for fecal incontinence. Regular physical activity can actually help with bowel movements by increasing muscle activity in the intestines. It is important for clients to maintain as much normal activity as possible.
Choice B Reason:
Limiting the client's fluid intake to 1500 mL/day is not advisable unless specifically recommended by a healthcare provider for another medical reason. Adequate hydration is essential for normal bowel function, and restricting fluids could exacerbate constipation, which can complicate fecal incontinence.
Choice C Reason:
Instructing the client to limit their intake of high-fiber foods would be counterproductive in managing fecal incontinence. A diet high in fiber can help form bulkier, softer stools, which can be easier to control. Fiber helps to regulate bowel movements, which is beneficial in bowel training programs.
Choice D Reason:
Assisting the client to the restroom 30 minutes after meals takes advantage of the gastrocolic reflex, which is a normal response where the act of eating stimulates movement in the gastrointestinal tract. This can help the client establish a regular pattern of bowel movements, which is a key goal in bowel training for fecal incontinence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Chilling the dialysate prior to infusion is not a recommended practice. The dialysate should be at body temperature to prevent discomfort and potential cramping during the infusion process. Chilled dialysate can also lead to vasoconstriction and decreased efficiency of the dialysis process.
Choice B Reason:
Using clean gloves when handling dialysate bags is a standard precaution to maintain sterility and prevent infection. However, it is not the primary action the nurse should take. The focus should be on the patient's weight management and monitoring for signs of fluid overload or deficit.
Choice C Reason:
Weighing the client before and after the treatment is crucial in peritoneal dialysis. It helps to monitor the fluid balance and the effectiveness of the dialysis treatment. Weight changes can indicate whether excess fluid is being removed or if there is fluid retention, which is essential for adjusting the dialysis prescription.
Choice D Reason:
Monitoring the client for diarrhea is important as it can lead to fluid and electrolyte imbalances. However, it is not specific to the dialysis procedure itself. The nurse should monitor for signs of infection, ensure proper catheter placement, and manage the dialysate's inflow and outflow, which are more directly related to peritoneal dialysis..
Correct Answer is A
Explanation
Choice A reason:
Using the client's left arm to obtain blood samples is the correct action to prevent lymphedema after a right radical mastectomy. Lymphedema can occur when the lymphatic drainage is disrupted, which is a risk after mastectomy involving lymph node removal. To reduce this risk, it is recommended to avoid procedures such as blood draws and blood pressure measurements on the affected side.
Choice B reason:
Obtaining blood pressure readings using the client's right arm, the side of the mastectomy, is not recommended. This action can increase the risk of lymphedema due to the pressure applied during the measurement, which can impede lymphatic flow and contribute to fluid accumulation.
Choice C reason:
Keeping both arms below the level of the client's heart is not specifically related to the prevention of lymphedema. While elevation of the affected arm can help promote lymphatic drainage and reduce swelling, there is no recommendation to keep both arms below heart level as a standard practice.
Choice D reason:
Limiting range-of-motion exercises with the affected arm is not advised as a means to prevent lymphedema. In fact, gentle range-of-motion exercises are encouraged postoperatively to prevent stiffness and improve mobility. However, these exercises should be performed carefully and gradually to avoid overexertion, which could lead to lymphedema.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.