A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care?

Administer a cathartic suppository 30 min prior to scheduled defecation times.

Encourage a maximum fluid intake of 1,500 mL per day.

Increase the amount of refined grains in the client's diet.

Provide the client with a cold drink prior to defecation.

Answer and Explanation

The Correct Answer is A

A. Correct. Administering a cathartic suppository can help stimulate bowel movement and facilitate a bowel-training program, particularly for individuals with altered bowel function due to spinal cord injury.

B. Incorrect. Adequate fluid intake is important, but limiting fluid intake is not typically recommended for clients with spinal cord injuries.

C. Incorrect. Refined grains are not specifically indicated for promoting bowel function. A balanced diet with sufficient fiber is more appropriate.

D. Incorrect. Providing a cold drink prior to defecation might not have a significant impact on bowel function and is not a commonly recommended intervention.

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Correct Answer is D

Explanation

A. Incorrect. Providing oral hygiene care is important but not the first priority after a client has vomited

B. Incorrect. While administering an antiemetic medication might be considered, providing oral hygiene care to the client is the immediate priority.

C. Incorrect. Replacing the NG tube is not typically the first action to take after a client vomits. Addressing oral hygiene and assessing the client's condition comes first.

D. Correct. Evaluating the functioning of the suction device is important as it helps to prevent aspiration of contents.

A. Place a towel roll under the client's neck. B. Position a pillow under the client's knees. C. Apply an orthotic to the client's foot. D. Align a trochanter wedge between the client's legs.

Correct Answer is C

Explanation

A. Incorrect. Placing a towel roll under the client's neck is a preventive measure to maintain proper cervical alignment, but it does not specifically address contracture prevention.

B. Incorrect. This can promote flexion of the knees, which may actually contribute to knee flexion contractures over time. While it might be comfortable for the client, it's not a preventive measure against contractures.

C. Correct. Orthotics can help maintain proper alignment of the foot and ankle, preventing foot drop and other related contractures. They are designed to support joints and muscles, minimizing the risk of stiffness and contracture formation.

D. Incorrect. Aligning a trochanter wedge between the client's legs might help prevent external rotation of the hips but does not specifically address contracture prevention.

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A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care?

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