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 ["A","B","C","D","E"]
Explanation
Choice E reason:
The first step in tracheostomy care is to explain the procedure to the client. This is crucial for obtaining informed consent and ensuring that the client understands what will happen during the care process. It also helps to alleviate any anxiety or fear the client may have about the procedure. Clear communication is essential for patient-centered care and establishes trust between the nurse and the client.
Choice A reason:
Once the procedure has been explained, the next step is to ensure a method to communicate during the procedure, especially since the client may be unable to speak normally due to the tracheostomy. Communication methods can include writing, gestures, or the use of communication boards. This step is vital for the safety and comfort of the client, allowing them to express needs or concerns during the procedure.
Choice C reason:
After establishing a communication method, the nurse should wear clean gloves to remove the tracheostomy dressing. This step is important to maintain sterility and prevent infection. The nurse must carefully remove the dressing to inspect the stoma site for any signs of infection or irritation and to prepare the site for cleaning.
Choice B reason:
Cleaning the inner cannula is the next step, using a small brush specifically designed for this purpose. The inner cannula must be kept clean to ensure an unobstructed airway and to prevent the buildup of secretions, which can lead to infection or breathing difficulties. This step requires meticulous attention to detail to ensure that all secretions are removed.
Choice D reason:
The final step is to apply clean tracheostomy ties. These ties secure the tracheostomy tube in place, preventing it from moving or being dislodged. Proper application of the ties is critical for the stability of the tracheostomy tube and the safety of the client. The ties should be snug but not too tight, allowing for slight movement and comfort.
Correct Answer is A
Explanation
Choice A reason:
Applying a cooling blanket is a critical intervention for a patient with malignant hyperthermia, a life-threatening condition characterized by a rapid rise in body temperature and severe muscle contractions following exposure to certain anesthetic agents. The cooling blanket helps to reduce the patient's body temperature, which can prevent further complications associated with hyperthermia.
Choice B reason:
Instilling a warm enema solution is not an appropriate action for malignant hyperthermia. This condition requires measures to reduce body temperature, not increase it. A warm enema could potentially worsen the hyperthermic state.
Choice C reason:
Administering meperidine (an opioid analgesic) intramuscularly is not recommended in the management of malignant hyperthermia. Meperidine does not play a role in the treatment of this condition and could complicate the clinical picture due to its pharmacological effects.
Choice D reason:
Ventilating the client with 50% oxygen is part of the supportive care for malignant hyperthermia, but it is not the primary intervention. The main goal is to treat the hypermetabolic state and reduce body temperature. While oxygenation is important, it should be accompanied by other specific treatments for malignant hyperthermia, such as administering dantrolene and active cooling measures.
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