A nurse is implementing a bowel training program for a client. For the program to be effective, the nurse should take the client to the toilet at which of the following times?

When the client has the urge to defecate

Every 2 hr while the client is awake

Immediately before the client has a meal

After the client feels abdominal cramping

Answer and Explanation

The Correct Answer is A

Choice A rationale: Taking the client to the toilet when they have the urge to defecate promotes a natural bowel pattern and is an essential aspect of bowel training.
Choice B rationale: Timing toilet visits based on a regular schedule may be part of a bowel training program, but waiting for the client to have the urge is more effective.
Choice C rationale: Timing toilet visits with meals may be part of a bowel training program, but taking the client when they have the urge is more effective.
Choice D rationale: Waiting for the client to experience abdominal cramping may lead to delayed toileting and is not recommended in a bowel training program.

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Correct Answer is A

Explanation

Choice A rationale: The client who is 92 years old, uses a walker, is incontinent, and has an extensive cardiac history is at higher risk for the development of pressure injuries due to age, immobility, and additional risk factors.
Choice B rationale: A client with paraplegia may be at risk for pressure injuries, but the combination of age, walker use, incontinence, and cardiac history increases the risk in Choice A.
Choice C rationale: A comatose client with a traumatic brain injury is at risk, but other factors in Choice A contribute to a higher overall risk.
Choice D rationale: A client who uses a cane and has dementia may be at risk, but the combination of age, walker use, incontinence, and cardiac history increases the risk in Choice A.

A. Request a prescription for the insertion of an indwelling urinary catheter. B. Apply a moisture barrier ointment to the client's skin C. Clean the client's skin and perineum with hot water after each episode of incontinence. D. Check the client's skin every 8 hr for signs of breakdown.

Correct Answer is B

Explanation

Choice A rationale: Inserting an indwelling urinary catheter is an invasive intervention and should be reserved for specific indications. It does not prevent skin breakdown.
Choice B rationale: Applying a moisture barrier ointment to the client's skin helps protect the skin from the harmful effects of urine and prevents breakdown.
Choice C rationale: Cleaning the client's skin and perineum with hot water after each episode of incontinence can lead to skin irritation and breakdown.
Choice D rationale: Checking the client's skin every 8 hours is not sufficient to prevent skin breakdown. Continuous assessment and prompt intervention are needed.

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A nurse is implementing a bowel training program for a client. For the program to be effective, the nurse should take the client to the toilet at which of the following times?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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