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
Explanation
Choice A Reason:
A healthy stoma should appear pinkish-red, indicating good blood supply and normal function. This coloration is similar to the inside of the mouth, which is also a mucous membrane. A pinkish-red stoma typically means that the colostomy is functioning properly and that the tissue is healthy.
Choice B Reason:
Absent bowel sounds can be a normal finding immediately postoperative as it may take some time for bowel function to return. However, absent bowel sounds alone do not indicate that the colostomy is functioning properly. Bowel sounds should be assessed in conjunction with other signs, such as the appearance of the stoma and the passage of stool or gas.
Choice C Reason:
While tolerating a clear liquid diet is a positive sign of recovery post-surgery, it does not directly indicate whether the colostomy is functioning properly. The ability to tolerate a clear liquid diet is more related to the overall condition of the gastrointestinal tract and the patient's ability to absorb and digest fluids.
Choice D Reason:
Passing of flatus (gas) through the stoma can be a sign that the colostomy is starting to function, as it indicates movement within the intestines. However, the passage of gas alone is not sufficient to determine if the colostomy is functioning properly. It must be accompanied by the passage of stool and a healthy-looking stoma.
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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