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 D
Explanation
Choice A Reason:
Placing a client with influenza in a negative airflow room is typically reserved for airborne infections like tuberculosis, not for influenza which is spread by droplets. Negative airflow rooms are designed to prevent the spread of infectious agents that are airborne and can remain infectious over long distances.
Choice B Reason:
Administering an influenza immunization to a client who already has influenza is not an immediate intervention in the care plan. Vaccination is a preventive measure before one contracts the disease. Once a client has influenza, the focus shifts to treatment and supportive care.
Choice C Reason:
While wearing an N95 mask can provide a higher level of protection, it is generally recommended for healthcare workers dealing with airborne diseases like tuberculosis. For influenza, standard droplet precautions, including wearing a surgical mask, are usually sufficient.
Choice D Reason:
This is the correct intervention. Having the client wear a surgical mask during transport helps prevent the spread of influenza to others by containing respiratory droplets.
Correct Answer is C
Explanation
Choice A Reason:
Using ibuprofen, which is a nonsteroidal anti-inflammatory drug (NSAID), is not recommended for patients taking enoxaparin. NSAIDs can increase the risk of bleeding, which is a concern when on anticoagulant therapy like enoxaparin. Patients are advised to use other types of pain relievers that do not have anticoagulant effects, such as acetaminophen.
Choice B Reason:
Avoiding the use of stool softeners is not necessary for patients taking enoxaparin. Stool softeners do not interfere with the action of enoxaparin and do not increase the risk of bleeding. They are often recommended to prevent constipation, which can be a concern for patients who are less mobile due to illness or surgery.
Choice C Reason:
Using an electric razor for shaving is a safe practice for patients on enoxaparin to prevent cuts and bleeding. Since enoxaparin is an anticoagulant, it increases the risk of bleeding, and even minor cuts from a manual razor can lead to excessive bleeding.
Choice D Reason:
Massaging the site after each injection of enoxaparin is not recommended. Massaging the injection site can cause the medication to disperse more rapidly than intended and can also increase the risk of bruising and bleeding.
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