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?

Assist the client to the restroom 30 min after meals.

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

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Assisting the client to the restroom 30 minutes after meals is correct recommendation. This intervention aligns with the natural response of the gastrocolic reflex, which often leads to increased colonic motility after eating. Timing the restroom visit to this period can take advantage of the body's natural tendency to have a bowel movement after meals, potentially aiding in achieving bowel continence.

Choice B Reason:

Limiting the client's physical activity until bowel continence is achieved is not appropriate. Physical activity can actually stimulate bowel function and regularity. Moderate physical activity, as appropriate for the client's condition, can promote regular bowel movements. Restricting physical activity might hinder the overall success of bowel training.

Choice C Reason:

Limiting the client's fluid intake to 1500 mL/day is not appropriate. Adequate hydration is crucial for bowel health and regularity. Limiting fluid intake could lead to dehydration and constipation, which can exacerbate fecal incontinence. It's important to encourage adequate hydration unless there are specific medical reasons to restrict fluids.

Choice D Reason:

Instructing the client to limit their intake of high-fiber foods is incorrect. High-fiber foods are beneficial for bowel regularity and can help manage fecal incontinence by promoting healthy bowel movements. Limiting high-fiber foods could potentially lead to constipation or exacerbate the issue of fecal incontinence.

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Free Nursing Study Resources

Correct Answer is A, B, C, D, E

Explanation

A. Cleanse the site with an antiseptic swab: Begin by cleaning the puncture site to reduce the risk of infection. B. Allow the site to dry: Let the antiseptic dry completely to prevent contamination or dilution of the blood sample. C. Pierce the puncture site quickly: Use a lancet to pierce the skin in one swift motion to minimize discomfort. D. Squeeze the site gently to obtain a blood droplet: Gently apply pressure to the site to encourage a droplet of blood to form. E. Apply blood to the test strip: Once the blood droplet forms, apply it to the test strip for analysis.

A. Prepare the sterile dressing supplies 30 min before the dressing change. B. Don sterile gloves before removing the dressing, C. Disinfect the wound bed with alcohol before applying tape. D. Offer the client pain medication before the procedure.

Correct Answer is D

Explanation

Choice A Reason:
Preparing the sterile dressing supplies 30 min before the dressing change is correct. While it's crucial to have all supplies ready before starting the procedure, preparing them 30 minutes in advance might not align with the principles of maintaining sterility. It's generally best to prepare sterile supplies just before the procedure to minimize the risk of contamination.
Choice B Reason:
Don sterile gloves before removing the dressing is incorrect. Sterile gloves should indeed be worn during the dressing change, but they should be put on after removing the old dressing. This ensures that the clean gloves don't touch potentially contaminated surfaces during the removal of the old dressing.
Choice C Reason:
Disinfect the wound bed with alcohol before applying tape is incorrect. Using alcohol to disinfect the wound bed is not recommended as it can cause tissue irritation and delay wound healing. Sterile saline or another wound cleansing solution prescribed for wound care would be more appropriate to clean the wound bed. Additionally, applying tape directly to the wound is generally avoided to prevent further damage to the fragile tissues of a pressure ulcer.
Choice D Reason:
Offering the client pain medication before the procedure is correct. Providing pain medication before the procedure ensures the client's comfort and helps manage any discomfort or pain associated with the dressing change, particularly when dealing with a stage III pressure ulcer, which can be quite sensitive.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A, B, C, D, E

Explanation

A nurse is preparing to perform a sterile dressing change for a client who has a stage III pressure ulcer. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

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